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Medically Approved by Dr Aqua Asif (Jun 18th 2025) and Mr Marc laniado Consultant Urologist GMC: 3343931. (24/3/2026)
Written by FTC Medical team
At a Glance
An MRI-targeted biopsy is currently the most accurate single test for diagnosing prostate cancer, recommended by NICE (guideline NG131) as part of a stepped diagnostic pathway. At The Focal Therapy Clinic, our consultant urological surgeons use multiparametric MRI (mpMRI) combined with targeted biopsy to ensure precise diagnosis — guiding over 2,000 patients toward the most appropriate treatment.
Key takeaways:
MRI-targeted biopsy: the most accurate diagnostic method, focusing on suspicious areas identified on mpMRI rather than random sampling<
PSA is a starting point: useful for initial screening but limited by false positives; further investigation is usually needed
NICE guideline NG131: recommends mpMRI as first-line investigation before biopsy for men with suspected prostate cancer
Early detection matters: men diagnosed with localised prostate cancer have more treatment options, including focal therapy which preserves 90%+ sexual function
Stepped pathway: diagnosis typically involves PSA blood test, then mpMRI, then targeted biopsy only if needed
Why Does Early Detection of Prostate Cancer Matter?
Early detection of prostate cancer gives men the widest range of treatment options and the best chance of preserving quality of life. There is currently no national screening programme in the UK, but NICE guideline NG131 recommends a clear diagnostic pathway — starting with a PSA blood test, followed by multiparametric MRI, and then targeted biopsy only if needed.
Common symptoms and risk factors
Early prostate cancer typically causes no symptoms at all – this is why discussions about testing are important even in men who feel completely well. Urinary symptoms such as difficulty starting urination, changes in urinary flow, or increased frequency (particularly at night) are much more commonly caused by benign prostatic hyperplasia (BPH) – a non-cancerous enlargement of the prostate that affects most men as they age.
When prostate cancer does cause symptoms, it’s often in more advanced stages and may include persistent bone pain, unexplained weight loss, or significant changes in urinary or bowel function. However, by this stage, treatment options may be more limited.
Key risk factors
Age over 50: risk increases significantly with age
Family history: particularly of prostate or breast cancer
African Caribbean ancestry: approximately double the risk compared to men of European ancestry
Why Is Early Diagnosis Important?
When prostate cancer is detected early, patients typically have significantly more treatment options available. For men diagnosed with localised cancer, treatments like focal therapy aim to target only the affected area while preserving healthy tissue. Research suggests this approach may help reduce the risk of side effects such as incontinence or erectile dysfunction compared to more extensive treatments.
In our clinic’s experience with over 2,000 procedures, focal therapy preserves sexual function in 90%+ of men and maintains urinary continence in 97% of patients (FTC audit, n=265). These outcomes are why accurate, early diagnosis is so important — the earlier cancer is found, the more likely a man is to be suitable for tissue-preserving treatment.
What Tests Are Used to Diagnose Prostate Cancer?
Prostate cancer diagnosis follows a stepped pathway recommended by NICE guideline NG131. Rather than a single test, clinicians use a combination of assessments — typically starting with a PSA blood test, progressing to multiparametric MRI (mpMRI), and then proceeding to targeted biopsy only if suspicious areas are identified.
Prostate-specific antigen (PSA) blood test
PSA is a protein made by the prostate, and a higher amount in your blood may signal a problem. Elevated levels can be caused by cancer, but also by non-cancerous issues like infection or an enlarged prostate. Because of this, further testing is usually needed to determine what’s really going on.
digital rectam examination (DRE)
A digital rectal examination (DRE) involves a doctor feeling the prostate through the rectum to check for any lumps or hard areas. While this is a straightforward examination, research indicates it has limited accuracy for detecting prostate cancer. It’s typically used alongside other assessments rather than as a standalone test. In recent years it has been de-emphasised in favour of MRI scanning.
Multiparametric MRI (mpMRI)
Multiparametric MRI provides detailed images of the prostate and surrounding tissues. Current NICE guidelines recommend mpMRI as a first-line investigation for men with suspected prostate cancer. It is commonly used when a PSA result is raised to guide whether a biopsy is needed. Many specialists consider mpMRI the best scan for prostate cancer currently available for initial assessment.
MRI Targeted prostate biopsy
When mpMRI identifies a suspicious area, an MRI-targeted biopsy takes tissue samples directly from that location for microscopic examination. This is the most accurate method for confirming a prostate cancer diagnosis. The PRECISION trial (Kasivisvanathan et al., 2018) showed that MRI-targeted biopsy detects 12% more clinically significant cancers than systematic biopsy, while reducing the detection of insignificant cancers by 13%.
“MRI-targeted biopsy has transformed how we diagnose prostate cancer. By focusing on areas the MRI highlights as suspicious, we can give men a more accurate diagnosis while reducing unnecessary tissue sampling.”
Mr Raj Nigam Consultant Urologist GMC: 3265226
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Emerging diagnostic approaches
Several newer tests are being developed that may improve prostate cancer detection while reducing unnecessary procedures.
Blood-based testing
Beyond standard PSA, several enhanced blood tests are now available that may provide additional information. These include the Prostate Health Index (PHI) and 4Kscore, which combine multiple biomarkers and show improved accuracy compared to PSA alone, potentially reducing unnecessary biopsies.
Advanced urine tests
Urine biomarker tests, such as PCA3, look for a gene that is more active in prostate cancer cells. A positive result suggests a higher likelihood of cancer and can help guide whether a biopsy is needed. This kind of testing is especially helpful for those with uncertain PSA levels and a relevant family history.
Genetic risk assessment
For men with strong family histories, genetic testing can identify inherited cancer predisposition genes like BRCA2. While not used for general screening, this information can help inform personalised risk assessment.
How Do Prostate Cancer Tests Compare?
No single test provides a complete picture. The most accurate diagnostic approach combines tests in sequence — using each result to guide whether further investigation is needed. NICE guideline NG131 establishes this stepped pathway to ensure men receive accurate diagnoses while avoiding unnecessary invasive procedures.
How Accurate is Each test?
Each diagnostic method has specific strengths. The PROMIS trial demonstrated that mpMRI has a negative predictive value of 89% for clinically significant cancer — meaning that men with a clear MRI can often safely avoid biopsy. When MRI does identify a suspicious area, targeted biopsy provides the definitive diagnosis.
- PSA: Widely available and non-invasive, but prone to false positives
- mpMRI: Excellent at visualising suspicious areas in the prostate and avoiding unnecessary biopsies in men with negative scans
- MRI-targeted biopsy: Currently provides the most definitive diagnosis when cancer is suspected
- Other biomarker tests: May help refine risk assessment, particularly in borderline cases
What Is the Diagnostic Experience Like?
Many men understandably worry about discomfort during diagnostic procedures. At The Focal Therapy Clinic, our consultants use a an MRI Guided transperineal approach for biopsies, which current evidence suggests has a lower infection risk than the transrectal route. The mpMRI scan itself is entirely non-invasive — it typically takes 30-45 minutes and requires no anaesthetic.
In our clinic’s experience, following the NICE-recommended pathway means that many men referred with a raised PSA do not ultimately need a biopsy at all, because their MRI shows no areas of concern.
Which Prostate Cancer Test Should You Have?
The right diagnostic approach depends on your individual circumstances. At The Focal Therapy Clinic, our consultant urological surgeons follow the NICE-recommended stepped pathway — beginning with PSA and clinical assessment, then using mpMRI to determine whether a biopsy is needed.
Factors influencing test selection
Doctors weigh several factors before recommending a test or combination of tests. These may include:
- Age and general health status
- Family history and genetic risk factors
- PSA levels and trends over time
- Presence of early symptoms
- Results of previous investigations
- Patient preferences and concerns
Discussing options with your healthcare provider
Having open conversations with your healthcare provider makes a big difference. Our experienced consultants can help explain test results, discuss medical suitability for different approaches, and guide you through the decision-making process.
FAQs
What is the most accurate test for prostate cancer?
An MRI-targeted biopsy is currently the most accurate single test for diagnosing prostate cancer. NICE guideline NG131 recommends that men with suspected prostate cancer should first have a multiparametric MRI (mpMRI), which identifies suspicious areas. If a suspicious area is found, a targeted biopsy takes tissue samples directly from that location. The PRECISION trial showed this approach detects 12% more clinically significant cancers than systematic biopsy. At The Focal Therapy Clinic, our consultant urological surgeons use this NICE-recommended pathway for every patient referral.
Do I need a biopsy if my PSA is raised?
Not necessarily. A raised PSA does not automatically mean you have prostate cancer — it can be elevated by non-cancerous conditions such as BPH or infection. Under the NICE-recommended pathway, an mpMRI is performed first. If the MRI shows no suspicious areas, a biopsy may not be needed. This approach avoids unnecessary invasive procedures while ensuring significant cancers are not missed.
What happens if prostate cancer is diagnosed?
If a biopsy confirms prostate cancer, your treatment options depend on the cancer’s grade, stage, and location within the prostate. For men with localised prostate cancer, focal therapy offers a tissue-preserving alternative to radical surgery or radiotherapy. In our clinic’s experience with over 2,000 procedures, focal therapy preserves sexual function in 90%+ of men and maintains urinary continence in 97% of patients (FTC audit, n=265). Discuss your options and lifestyle consideration with your consultant
References
Cornford P, et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer-2024 Update. Part I: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2024;86(2):148-163.
NICE. Prostate cancer: diagnosis and management. NICE guideline [NG131]. 2019 (updated 2021).
Merriel SWD, et al. Systematic review and meta-analysis of the diagnostic accuracy of prostate-specific antigen (PSA) for the detection of prostate cancer in symptomatic patients. BMC Med. 2022;20(1):54.
Rosario DJ, et al. Short term outcomes of prostate biopsy in men tested for cancer by prostate specific antigen: prospective evaluation within ProtecT study. BMJ. 2012:344:d7894.
Ahmed HU, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet. 2017;389(10071):815-822.
Kasivisvanathan V, et al. MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis. N Engl J Med. 2018;378(19):1767-1777.
Diamand R, et al. Transperineal or Transrectal Magnetic Resonance Imaging-targeted Biopsy for Prostate Cancer Detection. Eur Urol Focus. 2024;10(5):805-811.
Russo GI, et al. A Systematic Review and Meta-analysis of the Diagnostic Accuracy of Prostate Health Index and 4-Kallikrein Panel Score in Predicting Overall and High-grade Prostate Cancer. Clin Genitourin Cancer. 2017;15(4):429-439.e1.
Vedder MM, et al. The added value of percentage of free to total prostate-specific antigen, PCA3, and a kallikrein panel to the ERSPC risk calculator for prostate cancer in prescreened men. Eur Urol. 2014;66(6):1109-15.
Van Neste L, et al. Detection of High-grade Prostate Cancer Using a Urinary Molecular Biomarker-Based Risk Score. Eur Urol. 2016;70(5):740-748.
Leongamornlert D, et al. Frequent germline deleterious mutations in DNA repair genes in familial prostate cancer cases are associated with advanced disease. Br J Cancer. 2014;110(6):1663-72.
This blog post is for informational purposes only and should not replace professional medical advice. Always consult with your healthcare provider about your specific situation and testing options.
