When you think of Sweden—which you probably don’t do often—what springs to mind? Maybe it’s tall blonde people, IKEA, or those cute painted horse carvings. Perhaps you picture Hollywood legends Greta Garbo and Ingrid Bergman, or you recall the cocktail party where the hostess served tasty Swedish meatballs. If you’re a music lover, you can thank Sweden for Spotify. Sweden also gave us scientific and intellectual giants whose names are eternally memorialized by their contributions, e.g., the Celsius temperature scale and the Nobel Prize.

Today, the Sperling Prostate Center celebrates another great Swedish gift. This time, it’s especially for prostate cancer (PCa) patients in the U.S. and world over. It’s called MRI Before Biopsy. It’s established by a 2023 published study on over 23,000 men who had PSA tests between Nov. 2011-2020, and who were monitored until Jan. 31, 2021 (none had PCa before the study).^[i] Data from the records includes PSA and repeated PSA results, prostate biopsies, and prostate MRI. If individuals were diagnosed with PCa during the study, Sweden’s National Prostate Cancer Register made their clinical factors accessible.

The 11 authors from several Swedish medical and academic centers represent specialties in urology, urologic surgery, radiology, and pathology. Their teamwork led to a conclusion with hugs ramifications for the PCa diagnostic pathway. Up till now, the standard next step for men with increased PSA levels has been a transrectal ultrasound (TRUS) guided needle biopsy. Bad enough was the number of men who didn’t need a biopsy because they didn’t have PCa. Worse still was the overdetection of insignificant PCa, or the underdetection of significant PCa. We have repeatedly posted about this problem since our first 2015 blog on the subject.

But here’s the good news. With the advent of prostate MRI, many research studies began to demonstrate a better path to diagnosis. The authors point to years of randomized studies showing the advantages of following an abnormal PSA with a prostate MRI instead of an immediate biopsy. By this approach, “…when the MRI findings are abnormal, MRI-targeted biopsies are obtained, whereas men with normal findings on MRI do not undergo biopsies.”^[ii] They wondered, would research findings hold up in ordinary community practice outside of a clinical study? Thus, they launched their own analysis.

They turned to patient records for men whose PSA results were abnormally high. Those in the earlier years (pre-2018) who went directly to TRUS biopsy were compared with those after 2018 when Swedish national guidelines recommended MRI before biopsy, and when targeted biopsy of suspicious lesions was becoming more common than systemic TRUS biopsy. Community practice results confirmed previous research studies. When MRI is done before biopsy, it results in:

• Fewer unnecessary biopsies (if the MRI scan was negative for suspicious lesions, no biopsy)
• More accurate biopsies (fewer insignificant/greater significant diagnoses).

This table summarizes their findings:

	No MRI before biopsy	MRI followed by biopsy if needed
% of insignificant PCa (< Gleason 6)	24%	6%
% of significant PCa (Gleason 7-10)	86%	49%

The authors define the importance of this study: “In randomized clinical trials (RCTs), magnetic resonance imaging (MRI) before prostate biopsy has been associated with fewer biopsies, decreased detection of Gleason score 6 cancers, and increased detection of Gleason score 7 or higher cancers. … Our results are in line with those of previous RCTs of men with clinical suspicion of prostate cancer. Our results support that all men with PSA between 3 and 20 ng/mL should undergo MRI before biopsy.”^[iii] [emphasis mine]

At the Sperling Prostate Center, we were ahead of our time in posting the importance of MRI before biopsy. All of our blogs on this topic since 2014 cite concurrent, relevant, high level research studies. The value of this latest gift from Sweden lies in the fact that it’s a broad population study with thousands of men, not simply a formal study with specific inclusion criteria (that is, a limited number of patients selected according to study design).

We thank the Swedish professionals who developed this new study. Their data analysis confirms our role as leaders and early adopters of MRI before biopsy, which is in the best interests of our patients. We knew it then, and we know it even more now. In addition, when our powerful 3T magnet reveals a suspicious lesion, we provide the most precise biopsy using real-time in-bore MRI guided targeting for the minimum number of needles and the maximum biopsy accuracy. Contact us for more information.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Robinson D, Abdulkareem R, Nasrollah D, et al. Frequency of Biopsy and Tumor Grade Before vs After Introduction of Prostate Magnetic Resonance Imaging. JAMA Netw Open. 2023;6(8):e2330233.
[ii] Ibid.
[iii] Ibid.