ideasIdea
MRI-first prostate screening with genetic pre-selection
PSA screening finds too many harmless cancers. Using PSA plus a genetic risk score to select men, and MRI before any biopsy, finds the dangerous ones and skips the rest.
GOTEBORG-2 showed MRI-targeted biopsy halves overdiagnosis; BARCODE1 showed polygenic-score-selected men have high rates of clinically significant cancer. The UK TRANSFORM trial will compare pathways. Propose a national screening design combining PRS/PSA pre-selection, MRI, and targeted biopsy only for PI-RADS 4-5 lesions.
Hypothesis
The combined pathway detects clinically significant (Gleason 7 and above) cancer at rates similar to PSA screening while cutting Gleason 6 detection by at least half and biopsies by at least 40%.
Rationale
Each component has randomised support; the combination is the programme design step.
What would test it
Embedded arm in TRANSFORM or a national pilot.
Maturity
being tested at scale
Who has to act
policy
Cost to try
Large (over $50M)
Years to first evidence
6
Bottlenecks it attacks
- Most lethal cancers are found late · Screening exists for only a few cancers. Pancreatic, ovarian, liver, oesophageal and most lung cancers are found when cure is unlikely.
- Overdiagnosis and false alarms · Finding more cancer is not the same as saving lives. Screening also finds cancers that would never have hurt anyone, and treats them.