Traditional PSA-based screening for prostate cancer (PCa) is challenged by an unfavorable benefit-to-harm ratio from underdiagnosis of clinically significant cancers, overdiagnosis of indolent cancers, and unnecessary biopsies, despite demonstrated reductions in PCa mortality. Inclusion of MRI in screening algorithms helps address these limitations by improving risk stratification of men suspected to have PCa and enabling targeted biopsies. The impact of MRI-based strategies on screening's benefit-to-harm ratio can be objectively assessed using ratios reflecting clinically significant cancers detected, indolent cancers detected, unproductive biopsies, and avoided biopsies. Among two overarching MRI-based screening strategies (sequential MRI after PSA testing and MRI alone), the sequential strategy is favored as a balanced and scalable approach. This article provides a detailed analysis of the role of MRI in PCa screening, targeted to radiologists. Recommendations are provided for optimizing use of MRI in PCa screening, including individualized risk assessments, tailored protocols, quality assurance for ensuring reliable and reproducible results, and consideration of new screening-specific scoring systems and biopsy thresholds. Ultimately, successful integration of MRI in PCa screening will require radiologists to actively engage in refining protocols, standardizing interpretations, and adopting emerging technologies. Such efforts will help maximize benefits while minimizing harms, enabling wider acceptance of PCa screening.
AJR. American journal of roentgenology. 2025 Feb 19 [Epub ahead of print]
Ivo G Schoots, Masoom A Haider, Shonit Punwani, Anwar R Padhani
Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands., Joint Department of Medical Imaging, Mount Sinai Hospital, Princess Margaret Hospital, University of Toronto, Toronto, Canada., Centre for Medical Imaging, University College London, London, United Kingdom., Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, United Kingdom.