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Veeru Kasivisvanathan, MBBS, BSc, FRCS, PhD, MSc, PGCert, reflects on the significant advancements in prostate imaging over the last decade, emphasizing the transformative role of MRI. A central question in this 15-minute presentation is whether prostate cancer can be diagnosed and managed without a biopsy. While biopsies are the current standard, they carry risks such as sepsis, patient discomfort, and financial burden.

The PROMIS study demonstrated MRI’s ability to detect all Gleason 4+3 cancers, though it also revealed MRI’s high number of false positives. Combining PSMA PET with MRI improves sensitivity to 97%, particularly for detecting clinically significant cancers, but specificity remains a challenge, raising concerns about unnecessary treatment. New scoring systems, like the P score, integrate PET avidity and PI-RADS scores to refine risk assessment and treatment decisions.

Kasivisvanathan discusses the concept of “biopsy-light” pathways, citing cohorts where patients undergo fewer biopsies, with monitoring driven by MRI and PSA changes. This approach shows promising compliance and oncological outcomes comparable to standard active surveillance but with less patient burden. Despite advancements, a fully biopsy-free pathway remains unfeasible due to limitations in MRI standardization, interpretation variability, and a lack of high-volume data.