Personalizing Prostate Cancer Diagnosis with Multivariate Risk Prediction Tools: How Should Prostate MRI Be Incorporated? - Beyond the Abstract

In this review, we conceptualize the diagnostic work-up of patients suspected of having clinically significant prostate cancer using combinations of MRI and multivariate prediction tools (risk calculators) and explore how together they can contribute to a personalized diagnosis.

The 2019 European Association of Urology (EAU) guidelines on prostate cancer recommend reducing (unnecessary) systematic biopsies by using prostate cancer risk calculators.1 To aid decision making with regard to the need for biopsy, these risk calculators have been developed to assess the likelihood of having clinically significant prostate cancer.2 These multiple validated risk calculators stratify men for further biopsy testing or clinical monitoring using readily available clinical parameters.

The 2019 EAU guidelines also recommend using PI-RADS compliant, multi-parametric magnetic resonance imaging (MRI) as a first-line diagnostic test in prostate cancer diagnosis, before any biopsy.1 This is a major change in the prostate cancer work-up. The basis lies in high-quality evidence, aggregated and analyzed in the Oxford Cochrane review.3,4 

Utilizing prebiopsy MRI in the prostate cancer workup has benefits:

  1. MRI and targeted biopsy increase detection of significant disease (prior negative biopsy > biopsy-naïve)
  2. MRI and targeted biopsy attenuate precision of tumor grade & volume estimation for most patients
  3. MRI reduces numbers of patients undergoing biopsy
  4. MRI reduces diagnoses of indolent disease
These MRI benefits are based on 50% all cancer prevalence and 30% significant cancer prevalence, and may therefore not be applicable to other prevalence. To reconcile the two recommendations from the 2019 EAU guidelines also dealing with the effects of prevalence, a bridging mechanism is needed as newly constructed MRI-based risk calculators are not-yet validated.

A matrix table is proposed to bridge the gap to new thresholds of developing and not-yet validated MRI-based risk calculators. This matrix table categorizes prostate cancer suspected men into men who may likely benefit from undergoing biopsies and who may not. Each cell within the matrix has an ascribed ‘biopsy action’, taken from the recommendation of the EAU 2019 prostate cancer guidelines and the PI-RADS steering committee pathway white paper.1,5 This proposal may guide biopsy-decision management on an individual basis in the increasingly complex approach of prostate cancer diagnosis.

PI RADS matrix

Example: A 69-old man with an all-cancer risk of 10% having an equivocal PI-RADS score 3 lesion on his prostate MRI may not benefit from undergoing biopsies. However, this man with an all-cancer risk of 25% should undergo a systematic biopsy and targeted biopsy of the PI-RADS 3 lesion. Based on low pre-biopsy risk calculation, an equivocal lesion on MRI can be monitored and biopsied when risk increases over time.

This individualized risk-adapted strategy for prostate cancer biopsy decision enables the balancing of benefits versus harms. It is important to identify only those men that are likely to benefit from timely diagnoses.

Written by: Ivo G. Schoots, MD, Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands, Twitter: @IvoSchootsNL; Anwar R. Padhani, MBBS, FRCP, FRCR, Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, United Kingdom, Twitter: @ProfPadhani


  1. European Association of Urology (EAU). Guidelines on prostate cancer. [online], (2019).
  2. Louie, K. S., A. Seigneurin, P. Cathcart, and P. Sasieni. "Do prostate cancer risk models improve the predictive accuracy of PSA screening? A meta-analysis." Annals of Oncology 26, no. 5 (2015): 848-864.
  3. Drost, Frank‐Jan H., Daniël F. Osses, Daan Nieboer, Ewout W. Steyerberg, Chris H. Bangma, Monique J. Roobol, and Ivo G. Schoots. "Prostate MRI, with or without MRI‐targeted biopsy, and systematic biopsy for detecting prostate cancer." Cochrane Database of Systematic Reviews 4 (2019).
  4. Drost, Frank-Jan H., Daniel Osses, Daan Nieboer, Chris H. Bangma, Ewout W. Steyerberg, Monique J. Roobol, and Ivo G. Schoots. "Prostate magnetic resonance imaging, with or without magnetic resonance imaging-targeted biopsy, and systematic biopsy for detecting prostate cancer: a Cochrane systematic review and meta-analysis." European urology 77, no. 1 (2020): 78-94.
  5. Padhani, Anwar R., Jelle Barentsz, Geert Villeirs, Andrew B. Rosenkrantz, Daniel J. Margolis, Baris Turkbey, Harriet C. Thoeny et al. "PI-RADS steering committee: the PI-RADS multiparametric MRI and MRI-directed biopsy pathway." Radiology 292, no. 2 (2019): 464-474.
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