Risk-adapted active surveillance for prostate cancer: Can mpMRI, biomarkers, and genomic classifiers reduce biopsy burden without compromising safety?: A systematic review.

Authors

Bilal Ahmad, Saad Masood, Shabir Zarif

Published in

Medicine. Volume 105. Issue 46. Pages e51498. Nov 13, 2026.

Abstract

Active surveillance is the preferred management strategy for men with low-risk and selected favorable intermediate-risk prostate cancer. However, conventional surveillance protocols rely heavily on repeated systematic biopsies, which impose procedural morbidity, patient burden, and limited precision in identifying true disease progression. Risk-adapted tools, including multi parametric magnetic resonance imaging (mpMRI), molecular biomarkers, and genomic classifiers, have emerged as potential strategies to optimize surveillance intensity while preserving oncologic safety. To systematically evaluate the evidence supporting risk-adapted AS strategies incorporating mpMRI, molecular biomarkers, and genomic classifiers, with a focus on reducing biopsy burden without compromising oncologic outcomes.
A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, and Scopus were searched for peer-reviewed studies evaluating mpMRI, molecular biomarkers, or genomic classifiers within AS cohorts. Randomized controlled trials and prospective or retrospective cohort studies reporting surveillance-related outcomes were included. Primary outcomes included biopsy upgrading or reclassification, AS failure, and oncologic safety endpoints. Due to methodological heterogeneity, results were synthesized narratively.
Five publications met inclusion criteria, representing four unique studies one randomized controlled trial and three observational cohorts and 1215 participants. The 2 Active Surveillance Magnetic Resonance Imaging Study publications were treated as linked reports from the same trial. Baseline mpMRI with targeted and systematic biopsy was associated with lower subsequent AS failure and upgrading, but biopsy avoidance was not directly tested. An MRI-led cohort omitted routine protocol biopsies, although the absence of a concurrent comparator precluded conclusions about equivalent oncologic safety. The 4Kscore demonstrated potential for confirmatory-biopsy triage; a hypothetical deferral strategy could have avoided 27% of biopsies but would have missed 2 Grade Group 2 upgrades. The Decipher genomic classifier independently predicted biopsy upgrading, although biopsy reduction was not evaluated. Evidence establishing the long-term oncologic safety of biopsy reduction remained insufficient.
Risk-adapted AS strategies incorporating mpMRI, molecular biomarkers, and genomic classifiers may improve risk stratification and support selective adjustment of biopsy intensity. However, current evidence does not establish the safety of routine biopsy omission or fully biopsy-free surveillance. Integration of these tools should remain individualized, with histologic reassessment when indicated and prospective validation of biopsy-deferral strategies.

PMID:
43024296
Bibliographic data and abstract were imported from PubMed on 14 Nov 2026.

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