MRI-based staging performed similarly to traditional digital rectal examination (DRE) staging for predicting oncological outcomes in men undergoing radical prostatectomy, according to a large multicentre study published in JAMA Network Open.
The findings suggest that MRI-derived T staging could potentially be incorporated into established prostate cancer risk classification systems in place of DRE-based staging without compromising prognostic discrimination, adding to the debate about the evolving role of DRE in contemporary prostate cancer care.
For decades, DRE has formed the basis of clinical T staging and remains incorporated into widely used risk classification systems. However, its role is increasingly being reconsidered as multiparametric MRI has become embedded in modern prostate cancer pathways, providing detailed anatomical information about local tumour extent. The retrospective, multicentre case-control study included 4,425 men with clinically localised or locally advanced prostate cancer who underwent radical prostatectomy between 2015 and 2021 at 31 referral centres across six European countries. All patients underwent both DRE-based clinical staging and preoperative multiparametric MRI, allowing direct comparison between the two approaches.
Researchers substituted MRI-derived T stage for conventional DRE-derived T stage within four established prostate cancer risk classification systems: D’Amico, the European Association of Urology (EAU), the National Comprehensive Cancer Network (NCCN) and the International Staging Collaboration for Prostate Cancer (STAR-CAP).
The primary outcome was distant metastasis-free survival, with biochemical recurrence-free survival and overall survival assessed as secondary outcomes.
After a median follow-up of 52 months, MRI-derived T stage showed slightly higher discrimination than DRE-derived staging for biochemical recurrence-free survival, with C indices of 0.62 (95% confidence interval [CI] 0.61–0.64) and 0.59 (95% CI 0.57–0.61), respectively.
For distant metastasis-free survival, the corresponding C indices were 0.67 (95% CI 0.64–0.70) with MRI-derived staging and 0.65 (95% CI 0.62–0.68) with DRE-derived staging, with overlapping confidence intervals.
Importantly, however, replacing DRE-derived T stage with MRI-derived stage within the four established composite risk classification systems did not significantly improve prognostic discrimination. MRI-adapted and conventional versions demonstrated broadly comparable performance for biochemical recurrence, distant metastasis and overall survival.
Similar findings were observed among patients with cT1 disease and those with prostate-specific antigen levels below 10 ng/mL, with no consistent improvement in prognostic discrimination when MRI-derived staging was substituted for traditional clinical staging.
The findings suggest that while MRI provides more detailed anatomical assessment, including identification of extraprostatic extension and seminal vesicle invasion, this greater anatomical precision does not necessarily translate into improved prediction of longer-term oncological outcomes when incorporated into existing risk models.
Rather than demonstrating that MRI is superior for prognostic assessment, the comparable performance of the two approaches suggests that MRI-derived staging may potentially be integrated into contemporary risk classification systems in place of DRE-derived staging without reducing their prognostic discrimination.
The findings are particularly relevant as the role of DRE continues to be reconsidered in modern prostate cancer care. With MRI increasingly used for lesion detection, biopsy targeting, local staging and treatment planning, the study adds to evidence informing the evolving role of DRE in contemporary prostate cancer staging.
For Australian clinicians, the findings are relevant to an increasingly MRI-led prostate cancer diagnostic pathway. They suggest that established risk classification systems may potentially be adapted to incorporate MRI-derived rather than DRE-derived T stage in men being considered for radical prostatectomy, although prospective validation would be required before widespread changes to staging frameworks or clinical guidelines.
The authors acknowledged several limitations, including the retrospective design and potential for selection bias and unmeasured confounding. MRI equipment and radiological expertise also varied between centres and were not centrally standardised, while pathological correlation of MRI findings was not uniformly validated across participating centres. Longer follow-up is needed to fully assess the prognostic performance of MRI-based staging for distant metastasis and overall survival.
Overall, the findings suggest that MRI-derived staging could potentially be integrated into contemporary prostate cancer risk classification systems without compromising prognostic discrimination, supporting further prospective evaluation of MRI-derived staging within contemporary prostate cancer risk classification systems.
Paper: Peyrottes A, Baboudjian M, Long-Depaquit T, et al. Performance of MRI-Based vs Clinical T Staging in Localized Prostate Cancer. JAMA Netw Open. 2026;9(7):e2623288. Access online here.
