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Prostate MRI is good at telling you whether a man has a serious cancer and poor at telling you where all of it is. It missed at least one significant tumour in a third of men in the study that checked it against the whole removed prostate. Services that treat part of the gland, or follow men on imaging alone, are relying on the number they do not measure.
PROMIS established per-patient performance: sensitivity of 93 percent for clinically significant cancer against a template mapping biopsy reference, with specificity of 41 percent, which is what justifies using the scan to decide whether to biopsy. Johnson and colleagues measured per-lesion performance by co-registering scans with whole-mount pathology in 588 prostatectomy specimens: 45 percent of all 1,213 foci detected, 65 percent of clinically significant ones, at least one clinically significant focus missed in 34 percent of men overall and 45 percent of men with multifocal disease.
Those two numbers answer different questions and are routinely quoted as if they answered the same one. A triage decision needs the first. Treating one part of the gland and leaving the rest, or following a man for years on imaging without biopsy, needs the second, and no service publishes it. Every centre performing radical prostatectomy after magnetic resonance imaging already generates the data required, because it has the scan and the whole gland. The proposal is that per-lesion sensitivity against whole-mount pathology, stratified by lesion size and grade, becomes a published quality metric, and a precondition for offering focal ablation or imaging-only surveillance.
The limit of what a prostate scan can be asked to do. It is a good triage test for whether to biopsy and a poor map of where every tumour is, which matters for anyone being offered treatment to part of the gland or follow-up by imaging alone.
Pre-biopsy MRI with targeted sampling is now the standard diagnostic pathway for suspected prostate cancer, reducing overdiagnosis of low-risk disease.
The evidence that put a scan in front of the biopsy. It reduces the number of men who are biopsied at all, reduces the number of harmless cancers found, and increases the number of dangerous ones, which is the only combination that improves a screening pathway on both sides at once.
Active surveillance is the preferred management for low-risk prostate cancer, and this cohort's triggers for intervention shaped surveillance protocols worldwide.
Shares Radical prostatectomy, Localised prostate cancer, intermediate risk, Localised prostate cancer, very low and low risk, Localised prostate cancer, high and very high risk and the tag prostate-evidence.
Shares Long-term follow-up of a large active surveillance cohort of patients with prostate cancer (Sunnybrook), Radical prostatectomy, Localised prostate cancer, intermediate risk, Localised prostate cancer, very low and low risk and the tag prostate-evidence.
Shares Radical prostatectomy, Gleason score / Grade Group, Localised prostate cancer, intermediate risk, Localised prostate cancer, high and very high risk and the tag prostate-evidence.
Shares MRI-first prostate screening with genetic pre-selection, PSA and MRI-first prostate cancer screening, Localised prostate cancer, intermediate risk, Localised prostate cancer, very low and low risk and the tag prostate-evidence.
Shares Long-term follow-up of a large active surveillance cohort of patients with prostate cancer (Sunnybrook), Gleason score / Grade Group, Localised prostate cancer, very low and low risk, Active surveillance and the tag prostate-evidence.
Shares PSA and MRI-first prostate cancer screening, Localised prostate cancer, intermediate risk, Localised prostate cancer, very low and low risk, Localised prostate cancer, high and very high risk and the tag prostate-evidence.
Shares Long-term follow-up of a large active surveillance cohort of patients with prostate cancer (Sunnybrook), Localised prostate cancer, very low and low risk, Overdiagnosis and false alarms, 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 and the tag prostate-evidence.
Shares Localised prostate cancer, intermediate risk, Localised prostate cancer, very low and low risk, Overdiagnosis and false alarms, 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 and the tag prostate-evidence.