Re: Jonas Hugosson, Marianne Månsson, Jona Wallström, et al. Prostate Cancer Screening with PSA and MRI Followed by Targeted Biopsy Only. N Engl J Med 2022;387:2126–37

We read with interest the report by Hugosson et al [[1]Hugosson J. Månsson M. Wallström J. et al.Prostate cancer screening with PSA and MRI followed by targeted biopsy only.N Engl J Med. 2022; 387: 2126-2137Crossref PubMed Scopus (5) Google Scholar] on their trial showing that prostate cancer screening with prostate-specific antigen (PSA) and magnetic resonance imaging (MRI) followed by targeted biopsy alone was associated with a modest decrease in the risk of detection of clinically insignificant prostate cancer in comparison to a strategy partly ignoring MRI results, despite high-level evidence supporting the use of MRI as a triage test to avoid any biopsy for lesions with a Prostate Imaging-Recording and Data System (PI-RADS) score of ≤2 [[2]Ahmed H.U. El-Shater Bosaily A. Brown L.C. et al.Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study.Lancet. 2017; 389: 815-822Abstract Full Text Full Text PDF PubMed Scopus (1740) Google Scholar]. Interestingly, when considering only men who underwent biopsy for positive MRI findings, we did not find a significant difference in the risk of detecting clinically insignificant prostate cancer between the experimental (n = 59/11 986; 0.5%) and reference (n = 31/5994; 0.5%) groups (see Table 3 in [[1]Hugosson J. Månsson M. Wallström J. et al.Prostate cancer screening with PSA and MRI followed by targeted biopsy only.N Engl J Med. 2022; 387: 2126-2137Crossref PubMed Scopus (5) Google Scholar]). This suggests that the benefit observed in the overall study population is related more to the use of MRI as a triage test to avoid any biopsy for PI-RADS ≤2 lesions than to the use of targeted biopsy alone. Thus, we believe that this trial does not support routine omission of systematic biopsy in men with positive MRI findings. Further research is needed to define the role of targeted biopsy alone for prostate cancer screening and identify patients who might benefit from this approach. However, this strategy is unlikely to suit all men regardless of PSA levels, MRI results, and available treatment options. In addition, the limited generalizability of this trial owing to the young age of participants (50–60 yr) and the single-center design in which expert urologists and radiologists were involved precludes widespread adoption of the proposed screening strategy, especially without any survival data available to support it. Conflicts of interest: Pierre Mozer has patents for a targeted biopsy device and has been involved in licensing of the Koelis UroStation system. Louis Lenfant and Thomas Seisen have nothing to disclose.