MRI imaging in prostate cancer screening reduces number of unnecessary prostate biopsies: JAMA

The systematic review and meta-analysis of 80 114 screened men from 12 studies revealed that MRI-based screening is associated with a reduced number of unnecessary prostate biopsies and detection of clinically insignificant prostate cancer while maintaining the detection of clinically significant prostate cancer versus prostate-specific antigen–only strategies. To balance these benefits and risks, clinical practice guidelines recommend shared decision-making strategies to identify informed candidates who are most likely to benefit from early detection of prostate cancer.

Prostate MRI is increasingly integrated within the prostate cancer early detection pathway. Therefore, Tamás Fazekas, Medical University of Vienna, Vienna, Austria, and colleagues systematically evaluate the existing evidence regarding screening pathways incorporating MRI with targeted biopsy and assess their diagnostic value compared with PSA–based screening with systematic biopsy strategies.

For this purpose, the researchers searched the online databases through May 2023. Randomized clinical trials (RCTs) and prospective cohort studies were eligible if they reported data on prostate MRI's diagnostic utility in the setting of PCa screening.

The researchers extracted data on biopsy indications, the number of screened individuals, clinically significant PCa (csPCa) defined as International Society of Urological Pathology (ISUP) grade 2 or higher, biopsies performed, and insignificant (ISUP1) prostate cancers detected.

The study's primary outcome was the detection rate of csPCa. Secondary outcomes included biopsy indication rates, clinically insignificant PCa detection rates, and the positive predictive value for the detection of csPCa.

The MRI-based and PSA-only screening strategies were compared. Based on the timing of MRI (primary/sequential after a PSA test) and cutoff (Prostate Imaging Reporting and Data System [PI-RADS] score ≥3 or ≥4) for biopsy indication, separate analyses were performed.

Data were synthesized from 80 114 men from 12 studies. Based on the analyses, the researchers reported the following findings:

• Compared with standard PSA-based screening, the MRI pathway (sequential screening, PI-RADS score ≥3 cutoffs for biopsy) was associated with higher odds of csPCa when test results were positive (OR, 4.15), insignificant cancers detected (OR, 0.34), and decreased odds of biopsies (OR, 0.28) without significant differences in the detection of csPCa (OR, 1.02).
• Implementing a PI-RADS score of 4 or greater threshold for biopsy selection was associated with a further reduction in the odds of detecting insignificant PCa (OR, 0.23) and biopsies performed (OR, 0.19) without differences in csPCa detection (OR, 0.85).

In conclusion, integrating MRI in prostate cancer screening pathways is tied to a reduced number of unnecessary biopsies and overdiagnosis of insignificant PCa while maintaining csPCa detection as compared with PSA-only screening.

"Our results highlight the need to reassess our approach to population-based screening; however, further evaluation is required on the optimal setup of MRI and biopsy scheme in the screening process," the researchers wrote.

Reference:

Fazekas T, Shim SR, Basile G, et al. Magnetic Resonance Imaging in Prostate Cancer Screening: A Systematic Review and Meta-Analysis. JAMA Oncol. Published online April 05, 2024. doi:10.1001/jamaoncol.2024.0734