Magnetic Resonance Imaging–based Biopsy Strategies in Prostate Cancer Screening: A Systematic Review

Abstract

Background and objective: Prostate cancer (PCa) screening using prostate-specific antigen (PSA) thresholding and systematic biopsies reduces advanced disease presentations and cancer-specific mortality, but also leads to overdiagnosis. Magnetic resonance imaging (MRI) integration may maintain screening benefits, while reducing overdiagnosis and unnecessary biopsies. This review analyses the benefit-harm balance when MRI is integrated as first-line and second-stage (after PSA >3 ng/ml) test in PCa screening. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we performed a PROSPERO-registered systematic review (CRD420251006926). Literature searches identified five first-line and four second-stage MRI screening studies. We assessed MRI strategies (first-line/second-stage and risk thresholds), biopsy avoidance, and biopsy methods (targeted/systematic) for histological outcomes (grade group [GG] ≥2/GG 1 cancer detection and benign biopsies). Benefit-to-harm ratios of >1 suggest a positive net benefit. Key findings and limitations: First-line MRI screening detects twice as many men with GG ≥2 cancer as second-stage MRI screening but has more MRI-negative men (range, 66–89% vs 56–61%). Second-stage MRI significantly reduced biopsy rates (range, 42–79%) compared with systematic biopsy rates in all PSA-positive men. Subsequently, GG ≥2/GG 1 cancer detection ratios increased in MRI-positive men undergoing targeted and systematic biopsies (range, 1.9–6.2) and targeted biopsies alone (range, 1.8–7.0), compared with systematic biopsies alone (range, 0.8–1.4). First-line and second-stage MRI screening allowed biopsy avoidance in three to 55 and two to 15 men, respectively, for each benign diagnosis. All benefit-to-harm ratios showed positive net benefits (>1). Heterogeneity in the study protocols limits generalisability. Conclusions and clinical implications: Targeted biopsies in second-stage MRI screening optimise clinically significant PCa detection, while reducing the number of biopsies. First-line MRI screening requires further assessments of its feasibility. PCa screening quality assurance requires standardised MRI interpretations and biopsy protocols.