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Prostate Biopsy: The Beginning of the End? with Dr. Mark Emberton

 

Prostate biopsy has long been treated as the default next step after an elevated PSA — but that pathway is rapidly changing. With high-quality prostate MRI (and, increasingly, PSMA PET), many men can now avoid unnecessary biopsies while still identifying the cancers that truly matter.

In this ASPI educational session, Prof. Mark Emberton (University College London) explains how MRI-first diagnosis is reshaping prostate cancer care. He reviews why biopsies can be difficult for patients and imperfect as a test, and he explores an emerging research question: whether biopsy-related trauma could have biological consequences in some cancers. He also outlines where the field may be headed — toward a “virtual biopsy” model that uses imaging and advanced analytics to estimate cancer risk and aggressiveness without routinely putting a needle into the prostate.

Follow along with the slides by downloading them here:
Prostate Biopsy – The Beginning of the End.

 

How MRI is Changing the Biopsy Pathway

For years, the pathway was straightforward: high PSA → biopsy. Dr. Emberton explains how that has shifted in parts of the UK, where men with a normal MRI are often reassured and may avoid biopsy altogether, while men with PI-RADS 3–5 findings can be managed more selectively.

He discusses how MRI helps clinicians focus on visible lesions (tumor masses) rather than diagnosing tiny, biopsy-only findings that may never become clinically meaningful. This change has major implications for men considering or living on Active Surveillance, where fewer invasive procedures can mean less anxiety, fewer complications, and a more evidence-based monitoring plan.

 

Why Biopsy Avoidance Matters — and What Research is Exploring

Biopsies can involve discomfort, bleeding, infection risk, and delays — and they can also be limited by sampling error. Dr. Emberton reviews why targeted biopsy is more precise than older “random” approaches, but still imperfect.

He also describes early scientific observations and questions under active study, including:

  • Whether biopsy can temporarily increase circulating tumor cells in the bloodstream
  • Rare case reports of needle-track seeding (both transrectal and transperineal)
  • Evidence from other cancers (e.g., breast cancer) showing measurable tissue and immune changes near biopsy sites

He emphasizes that prostate-specific evidence is still limited — and highlights the need for well-designed studies comparing biopsy vs no biopsy strategies.

 

What “Virtual Biopsy” Could Look Like

Dr. Emberton outlines a future where decision-making relies on multiple non-invasive inputs, including:

  • MRI (including advanced diffusion methods and newer sequences)
  • PSMA PET (to confirm likelihood of clinically significant cancer and assess spread)
  • Radiomics and AI feature extraction (to identify imaging patterns linked with risk)
  • Potential new approaches that assess tumor metabolism non-invasively

He also discusses early reports (in carefully selected cases) where men with strongly positive imaging results proceeded straight to radical prostatectomy without a pre-treatment biopsy — a concept still evolving and not yet standard.

 

Watch the Discussion

Chapters

  • 00:00 – Welcome, ASPI notes, and meeting introductions
  • 08:39 – Why biopsy used to be the default pathway
  • 12:18 – Biopsy harms, costs, and sampling limits
  • 16:05 – Trauma biology: what biopsy could (theoretically) change
  • 18:28 – Biopsy example and discussion of material entering nearby veins
  • 22:10 – Circulating tumor cells after biopsy: research overview
  • 24:27 – Rare tract-seeding reports (transrectal and transperineal)
  • 27:20 – What breast cancer research suggests about biopsy-related changes
  • 37:45 – How men can avoid biopsy today (MRI-first strategies)
  • 40:42 – “Straight to prostatectomy” concept (MRI + PSMA PET in selected cases)
  • 48:04 – Toward “virtual biopsy”: imaging, AI, and improving precision
  • 55:44 – Example of an early, very small lesion: watch vs treat vs biopsy
  • 57:32 – Lesion growth and natural history data discussed
  • 1:02:21 – Live Q&A with ASPI participants

 

 

About the Speaker

Prof. Mark Emberton is Professor of Interventional Oncology at University College London (UCL) and a leading figure in modern prostate cancer diagnosis. He has helped shape MRI-first pathways for prostate cancer care, including targeted biopsy approaches, imaging-based active surveillance strategies, and research into focal therapy and advanced prostate imaging.

His work has contributed to major changes in how prostate cancer is detected and managed — with a growing emphasis on identifying clinically meaningful disease while reducing unnecessary procedures.

 

Learn More About Prostate MRI, Biopsy & Active Surveillance

 

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