MRI before biopsy, & then fusion biopsy if targets found (?)

Maybe there are some rare exceptions to your statement, but what you say makes sense to me. Others here are way smarter than me and they will share their opinions.

My local urologist, during years of active surveillance, never once suggested an MRI. After getting 2nd, 3rd opinions I now think he was wrong. The 2 MRIs that I got helped track the progress and were successfully used during a repeat/fusion biopsy.

I guess my question is how likely is clinically significant cancer to be found after a systemic biopsy (lets say transrectal) when a Pirads 1 or 2 MRI found nothing suspicious to target? Wouldn't the approach to dealing with a localized 3+3=6 or 3+4=7 (with a small percentage of 4) still be continued active surveillance?

Apropos of this discussion, I just saw this January 20, 2026 article from Urology Times talking about a phase 3 trial called Bypass that is testing whether PSMA Pet scan should be used preliminarily as a way to evaluate whether you have prostate cancer before a biopsy. Insurance issues notwithstanding, it may be worth a discussion with your doctor.
https://www.urologytimes.com/view/study-launches-of-mri-plus-psma-pet-imaging-for-prostate-cancer-detection

@ezupcic

I'm open to being wrong, but I agree with what you are saying, because MRI has better sensitivity than conventional US.

The following is an exaggeration on my part, but it helps me remember the difference between sensitivity and specificity:

MRI has better SENSITIVITY than conventional US (finding true positives - all nodules that are even possibly cancerous will be visible - you'll have lots of targets, but if you target all of them you'll obliterate the prostate).
Conventional ultrasound has better SPECIFICITY than MRI (finding true negatives - only nodules that are obviously cancerous will be visible - you might miss some, but by limiting the number of targets, you won't obliterate the prostate).

It's "systematic" not "systemic", btw.🙂

@bens1
My limited research indicates that PSMA PET is definitely a superior in finding cancer that has spread outside of the prostate...is it also superior within the prostate?

Unfortunately, even if a patient in the United States is willing to pay cash for the $10-20K PSMA PET scan, the patient may have to switch urologists to find one that will prescribe the PSMA PET scan.
My urologist only grudgingly agreed to an MRI, and actually became angry when I asked about the possibility of a fusion biopsy.
Yes, I'm switching urologists.

In general, I agree with the statement you made about always getting an MRI first because you want to see if there are any lesions to target during a fusion biopsy. If an MRI shows no lesions to target but your PSA remains persistently high, either go straight to a biopsy anyway or consider using a new blood test called EpiSwitch that is 94% accurate on predicting whether a patient will have a positive biopsy sample for cancer. If you and your doctors think you are on edge of whether a biopsy is needed or not, consider using the EpiSwitch test to help make the biopsy decision. See more on EpiSwitch here https://www.94percent.com/
See my bio for more details.

@jercalif
While the PSMA PET scan works well to find metastasis outside the prostate. It is not capable of doing the detailed. imaging within the prostate itself. As a result, an MRI is much superior to a PET scan to look for anatomical details of the prostate.

Getting an MRI first is becoming the standard for proper treatment. You then want a fusion transperennial biopsy using the MRI as a guide.

The only problem with this is that in some cases the cancer does not show up in an MRI. If somebody has a high PSA getting a PSE test can show whether or not there is cancer in the body, Even if the MRI shows nothing.

@jeffmarc No doubt, a high quality 3T MRI shows more anatomical details of the prostate than a PSMA PET scan does. But since some cancers can be invisible to even a high quality MRI scan, those same cancer cells invisible to an MRI are not invisible to a PSMA PET scan. As such, a case can be made that a PSMA PET scan is better than an MRI just for the simple detection of the presence of cancer or not. Of course, there are also a few rare cancer variants that don't register on a PSMA PET scan either.

Agree strongly. I had two 12 core needle biopsies over two years apart which showed nothing despite an advancing PSA. DRE was normal. When 24 core was suggested, I insisted on an MRI, which showed the lesion to the anterior part of the prostate, which I like to call "the dark side of the moon" This allowed for a targeted biopsy. When discovered, PSA was over 17 and I had extracapsular extension and Gleeson 4-3. Can't help but think had the CX been discovered 2-3 yrs earlier, might not now be dealing with BCR. This was 11 yrs ago, so perhaps getting an MRI at outset is now standard of care?