Can MRI replace the rectal exam for prostate cancer staging?

Clinical takeaway: For men with localized prostate cancer undergoing radical prostatectomy, MRI-based T staging can be integrated into established risk classification systems without meaningfully changing predictions of recurrence, metastasis, or survival. MRI may add value for treatment planning and surgical decision-making, but not necessarily for prognostic discrimination.

MRI has become the preferred imaging modality for local prostate cancer staging, but most risk models still rely on digital rectal examination (DRE). These findings support replacing DRE-derived T stage with MRI-derived staging in contemporary prognostic systems without sacrificing predictive accuracy.

In this multicenter retrospective study, investigators analyzed 4,425 men (median age, 66 years) with localized or locally advanced prostate cancer who underwent preoperative multiparametric MRI and radical prostatectomy at 31 European centers. Over a median follow-up of 52 months, 25% experienced biochemical recurrence and 8.5% developed distant metastases. Although MRI assigned a higher local T stage than DRE in many patients—including approximately 20% classified as T3 or higher—this stage migration did not improve prediction of clinically meaningful outcomes.

MRI-based staging showed only modestly better discrimination than DRE alone for biochemical recurrence and distant metastasis, but when incorporated into major risk classification systems (D'Amico, EAU, NCCN, and STAR-CAP), MRI- and DRE-based models performed essentially the same for biochemical recurrence, metastasis-free survival, and overall survival. Results were similar among men with clinically nonpalpable tumors or PSA levels below 10 ng/mL. The authors conclude, "MRI-derived staging could be integrated into contemporary risk classification systems without compromising accuracy."

In an accompanying editorial, Chadi Nabhan, MD, MBA, MPP, and Charles L. Bennett, MD, PhD, MPP, MS(Law), note that the findings highlight an important distinction: "MRI answers the question of where the tumor is... but does not fully address tumor aggressiveness." They conclude that MRI's greatest value lies in improving diagnostic precision, surgical planning, and potentially quality of life rather than enhancing prognostic discrimination, while suggesting future risk models should incorporate genomic markers and artificial intelligence alongside imaging.

Source: Peyrottes A, et al. (2026 July 15) JAMA Netw Open. Performance of MRI-Based vs Clinical T Staging in Localized Prostate Cancer