The decision for precision.

Top Line: The PRECISION trial suggested MRI-targeted prostate biopsies are better than the standard 12-core approach in detecting clinically-significant prostate cancer (csPC) of at least Gleason 3+4, but some argue doing them both is best of all.
The Study: The aptly-named MRI-FIRST trial enrolled 251 men referred for prostate biopsy without a PSA >20 nor palpable extracapsular extension. And, you guessed it, everyone underwent diagnostic prostate MRI first. Where this differs from PRECISION is that everyone then received standard 12-core biopsies, and only those with suspicious MRI findings received sequential targeted biopsies. “Suspicious” was defined as a Likert score ≥3, i.e. using a more gestalt-y version of PIRADS. Among the 206 (82%) patients with a suspicious MRI, 8 were found to have csPC only upon 12-core biopsy yielding a targeted-biopsy false-negative rate of 6% (8 of 125 negative results). Of the 45 patients without a suspicious MRI, another 5 were found to have csPC upon 12-core biopsy yielding a diagnostic MRI false-negative rate of 11%. Taken together, the PRECISION approach of MRI first followed by targeted biopsy when suspicious yielded a false-negative rate of 8% (13 of 170 negative diagnostic MRIs and/or targeted biopsies). Finally, when considering number of biopsies needed to detect one csPC, 810 targeted biopsies detected 81 csPC (number needed = 10) while the additional 3070 biopsies using the 12-core approach detected an additional 13 csPC (number needed = 236).
Bottom Line: Unsurprisingly (a few) more clinically-significant prostate cancers were detected with (substantially) more biopsies, and while the authors conclude both techniques are needed, the clinical utility of this lies in the prostate of the beholder. | Rouvière, Lancet Oncol 2018


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