What is prostate cancer?

Prostate cancer is the most common non-skin cancer among men. In the US, over 300,000 new cases were projected for 2025. However, if diagnosed and treated early, cancer-specific survival is nearly 100% at five years and 98% at 10 years.

Yet many men avoid tests used to screen for prostate cancer. They worry that screening may lead to diagnosis, which in turn may lead to unnecessary treatments. Whole gland treatments like prostatectomy and radiation offer good cancer control but have side effect risks like urinary problems, sexual dysfunction, or bowel problems. If side effects are long-term, quality of life is reduced.^[i]

The Sperling Prostate Center understands the dilemma men face. Dr. Dan Sperling and his staff are pioneers in the use of MRI for accurate diagnosis to help avoid overbiopsy and overtreatment.

How has prostate cancer traditionally been diagnosed?

Until recently, prostate cancer has traditionally been diagnosed along a three-step pathway:

• Step One: A suspicious PSA blood test result and/or abnormal digital rectal exam (DRE)
• Step Two: To clarify suspicious results, have a needle biopsy using 12 or more needles guided by transrectal ultrasound (TRUS). If positive, develop a treatment plan.
• Step Three: If the biopsy is negative for cancer, monitor with future PSA/DRE testing and repeat biopsy as necessary.

NOTE: a prostate biopsy is necessary to diagnose prostate cancer. While multiparametric MRI and liquid tests for biomarkers may detect the presence of prostate cancer, examining tissue samples from a biopsy is still the only way to determine the presence and aggression level of cancer cells.

Are there problems with traditional screening methods?

The traditional PSA test and DRE have problems:

1. The PSA blood test is not specific for prostate cancer. It can mean other noncancerous conditions: benign prostatic hyperplasia (BPH, an aging-related prostate enlargement); prostatitis; or prostate stimulation, such as sexual orgasm or even riding a bike.
2. The DRE is limited because a doctor’s finger can feel only one surface of the prostate gland, not the entire gland. It can miss prostate cancer in areas the doctor can’t feel.

Even if a PSA test result is high or a doctor feels a lump, more information is needed. Therefore, the doctor orders a biopsy. However, traditional TRUS-guided prostate biopsy has problems.

What are the problems with a TRUS biopsy?

A TRUS biopsy has some problems because it is essentially “blind.” Ultrasound cannot distinguish cancer from healthy tissue. The doctor takes needle samples according to a grid, in hopes of collecting clinically significant cancer. The more needles, the greater the chance of hitting clinically significant cancer.

A blind TRUS-guided prostate biopsy using 12 or more needles has four main problems:

1. It can pick up prostate cancer cells that pose little risk of becoming life-threatening. This is called insignificant or indolent (“lazy”) prostate cancer, and may not require treatment.
2. It can miss significant prostate cancer that requires treatment. This puts a patient at risk of dangerous cancer continuing to grow. Also, repeat biopsies may miss the same area until the tumor has become quite large or has started to grow beyond the gland.
3. It may not represent the true size, location, and aggression level. This can lead to overtreating insignificant cancer, or undertreating significant cancer that was missed on TRUS biopsy.
4. It can cause complications like pain, infection, blood in urine or semen, and erectile dysfunction.

Is there a better diagnostic pathway?

Yes, there is a new diagnostic approach called the MRI pathway for diagnosing clinically significant prostate cancer.^[ii] It was developed and tested under a cooperative MRI project in Berlin, Germany, called the PROKOMB Study, launched in 2017.^[iii] Its objective was to test if multiparametric MRI before biopsy could improve the diagnostic pathway, helping to avoid unnecessary biopsies for men whose PSA and/or DRE had suspicious results.

The study achieved its goal. According to spokesperson Dr. Peter Seidensticker (Head of Medical Affairs Radiology at Bayer, a study sponsor), “The core finding of the PROKOMB study showed that men with non-suspicious MRI can avoid biopsies without being at increased risk of clinically significant prostate cancer. To be precise, the study shows that an MRI-informed strategy could prevent biopsies in 41% of all men, and 86% of MRI-negative men over three years.”

How does the MRI pathway reduce unnecessary biopsies?

Multiparametric MRI helps eliminate unnecessary biopsies by identifying patients whose MRI scans do not show areas suspicious for clinically significant prostate cancer. This greatly reduces the number of men sent for a biopsy.

What makes MRI biopsy more accurate than TRUS?

If the MRI reveals a suspicious prostate cancer tumor, a standard TRUS biopsy many not be needed. The patient can have a more accurate biopsy performed in the MRI magnet. This is called a real time, in-bore MRI guided biopsy.

Because this type of biopsy is highly targeted and precise, it typically uses only 2-4 needles directed into the core of the suspicious area seen in real-time on MRI. This is where the most dangerous cells are likely to be found. Therefore, this is a minimalist biopsy yet it allows the most accurate diagnosis.

The MRI pathway for diagnosing clinically significant prostate cancer makes it possible to tailor a treatment plan to the patient’s disease. This affords the highest probability of successful cancer control. In many cases, image-based planning may also help reduce the risks of treatment side effects.

Does the Sperling Prostate Center offer the MRI diagnostic pathway?

Yes, the Sperling Prostate Center offers the MRI diagnostic pathway. Dr. Dan Sperling is a recognized expert in multiparametric MRI for detecting, diagnosing, and treating prostate cancer. His center is equipped with a powerful, state-of-the-art 3 Tesla magnet.

In addition, Dr. Sperling was an early adopter of Artificial Intelligence-based programs that boost efficiency and accuracy of multiparametric MRI scans. For appropriate patients he offers minimally invasive image-guided focal treatments like Focal Laser Ablation and TULSA.

The Sperling Prostate Center provides alternative solutions to the overdiagnosis/overtreatment problems associated with the traditional diagnostic pathway. Early detection and accurate diagnosis save lives. Thanks to Dr. Sperling’s MRI-based clinical services, men can confidently have annual PSA tests, knowing that a noninvasive scan can avoid an unnecessary biopsy.

Frequently asked questions (FAQ)

Q: What is the advantage of an MRI guided targeted biopsy over a TRUS biopsy?

A: An MRI guided targeted biopsy has three main advantages over a TRUS biopsy.

• MRI reveals a suspicious tumor that TRUS cannot distinguish, so the doctor can see where to aim the needles.
• MRI targeting requires only a minimum number of needles, typically 2-4, instead of 12 or more required for TRUS biopsy.
• MRI targeting directly samples the core of the suspicious tumor, where the most aggressive cancer cells are likely to be. This means a diagnosis that accurately reports the true nature of the disease.

Q: Is a fusion-guided biopsy the same as an MRI guided targeted biopsy?

A: No, fusion is not the same as a real time (in-bore) MRI targeted biopsy. Some doctors call fusion an MRI biopsy, but this is misleading. Fusion is a hybrid form of guidance. Fusion biopsy merges MRI and ultrasound images. However, this method can introduce small alignment errors.

Slight differences can occur, because the MRI is not live, and the patient is in a different position for TRUS than for the MRI. Also, patient movement during TRUS—even breathing or coughing—can affect the accuracy of the co-registration.

To compensate for possible inaccuracy, fusion guided biopsies involve 12 or more extra needles in hopes that no cancer in the gland is missed. Research shows that fusion biopsy is more accurate than TRUS^[iv], but true (live) MRI targeting is superior at detecting clinically significant prostate cancer when comparing the contents of each needle.^[v]

Q: Can multiparametric MRI completely replace biopsy for some men?

A: No, multiparametric MRI does not replace a needle biopsy, which is still the only way to prove the presence of prostate cancer cells. However, this type of MRI depicts tissue properties that characterize clinically significant prostate cancer.

If none of these properties are seen, a biopsy can be avoided and the patient can be safely monitored. However, when these properties are seen, real time MRI is used to aim a minimum number of biopsy needles into the core of the suspicious area. This minimalist biopsy is precise and therefore offers the most accurate diagnosis available.

Content reviewed by Dr. Dan Sperling, M.D., DABR — updated November 2025

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.

References

[i] Davis KM, Kelly SP, Luta G, Tomko C et al. The association of long-term treatment-related side effects with cancer-specific and general quality of life among prostate cancer survivors. Urology. 2014 Aug;84(2):300-6.
[ii] Hamm CA, Asbach P, Pö

About Dr. Dan Sperling

Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.