# Prostate active surveillance without scheduled biopsies: MRI and blood tests decide

Source: https://onco.cc/ideas/idea-prev-prostate-as-triggered-biopsy/  
OnCo record `idea-prev-prostate-as-triggered-biopsy` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Men on active surveillance for prostate cancer have repeat biopsies every year or two, a burden that drives some towards surgery. Triggering biopsy only when MRI, PSA density or new markers change, tested against scheduled biopsy in a 2,000-man non-inferiority trial, could be just as safe with far fewer biopsies.

## Summary

Men on active surveillance for prostate cancer have repeat biopsies every year or two, a burden that drives some towards surgery, so this idea triggers biopsy only when MRI, PSA density or new markers change. PRECISE MRI criteria and PSA density predict progression, MRI stability has high negative predictive value, and scheduled biopsies mostly find unchanged disease. A non-inferiority RCT would compare biomarker and MRI-triggered biopsy with protocol biopsy, using metastasis-free survival at eight years and biopsies per patient as endpoints. The test is a 2,000-man multicentre trial. At early-clinical maturity it addresses the bottlenecks Overdiagnosis and false alarms and Toxicity and quality of life are undervalued.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: Triggered biopsy reduces biopsies by at least 60% with metastasis-free survival non-inferior (margin 2 percentage points).
- Rationale: Biopsy burden drives men to choose surgery; MRI stability has high negative predictive value.
- Proposed test: 2,000-man multicentre RCT.
- Maturity: early-clinical
- Actor: clinic

## Sources

- Bottleneck evidence (Overdiagnosis and false alarms): Welch & Black, Overdiagnosis in cancer (JNCI 2010): https://doi.org/10.1093/jnci/djq099

## Connected records

- roadmaps: [Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch](https://onco.cc/roadmaps/prostate-roadmap/)
- ideas: [Publish a per-lesion miss rate for every prostate MRI service before it is allowed to guide focal treatment](https://onco.cc/ideas/idea-prostate-per-lesion-mri-audit-before-focal-treatment/)
- cancers: [Prostate cancer](https://onco.cc/cancers/prostate/)
- fronts: [Early Detection & Screening](https://onco.cc/fronts/early-detection/), [Imaging](https://onco.cc/fronts/imaging/)
- technologies: [Liquid biopsy (ctDNA)](https://onco.cc/technologies/liquid-biopsy/), [MRI](https://onco.cc/technologies/mri/)
- terms: [PI-RADS (Prostate Imaging Reporting and Data System)](https://onco.cc/terms/pi-rads/), [Template mapping biopsy (transperineal template prostate mapping)](https://onco.cc/terms/template-mapping-biopsy/)
- bottlenecks: [Overdiagnosis and false alarms](https://onco.cc/bottlenecks/b-overdiagnosis/), [Toxicity and quality of life are undervalued](https://onco.cc/bottlenecks/b-toxicity-qol/)
- key papers: [Overdiagnosis in cancer](https://onco.cc/key-papers/paper-welch-j-natl-cancer-inst/)

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