Magnetic Resonance Imaging in Prostate Cancer Screening: A Systematic Review and Meta-Analysis

Abstract

Importance: Prostate magnetic resonance imaging (MRI) is increasingly integrated within the prostate cancer (PCa) early detection pathway.

Objective: To systematically evaluate the existing evidence regarding screening pathways incorporating MRI with targeted biopsy and assess their diagnostic value compared with prostate-specific antigen (PSA)-based screening with systematic biopsy strategies.

Data sources: PubMed/MEDLINE, Embase, Cochrane/Central, Scopus, and Web of Science (through May 2023).

Study selection: Randomized clinical trials and prospective cohort studies were eligible if they reported data on the diagnostic utility of prostate MRI in the setting of PCa screening.

Data extraction: Number of screened individuals, biopsy indications, biopsies performed, clinically significant PCa (csPCa) defined as International Society of Urological Pathology (ISUP) grade 2 or higher, and insignificant (ISUP1) PCas detected were extracted.

Main outcomes and measures: The primary outcome was csPCa detection rate. Secondary outcomes included clinical insignificant PCa detection rate, biopsy indication rates, and the positive predictive value for the detection of csPCa.

Data synthesis: The generalized mixed-effect approach with pooled odds ratios (ORs) and random-effect models was used to compare the MRI-based and PSA-only screening strategies. Separate analyses were performed 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.

Results: Data were synthesized from 80 114 men from 12 studies. Compared with standard PSA-based screening, the MRI pathway (sequential screening, PI-RADS score ≥3 cutoff for biopsy) was associated with higher odds of csPCa when tests results were positive (OR, 4.15; 95% CI, 2.93-5.88; P ≤ .001), decreased odds of biopsies (OR, 0.28; 95% CI, 0.22-0.36; P ≤ .001), and insignificant cancers detected (OR, 0.34; 95% CI, 0.23-0.49; P = .002) without significant differences in the detection of csPCa (OR, 1.02; 95% CI, 0.75-1.37; P = .86). 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; 95% CI, 0.05-0.97; P = .048) and biopsies performed (OR, 0.19; 95% CI, 0.09-0.38; P = .01) without differences in csPCa detection (OR, 0.85; 95% CI, 0.49-1.45; P = .22).

Conclusion and relevance: The results of this systematic review and meta-analysis suggest that integrating MRI in PCa screening pathways is associated with a reduced number of unnecessary biopsies and overdiagnosis of insignificant PCa while maintaining csPCa detection as compared with PSA-only screening.

Figure 1.. Flowchart of the Study Selection Process

Figure 2.. Comparison of Magnetic Resonance Imaging (MRI) and Standard Prostate-Specific Antigen (PSA)–Based Screening Strategies in Terms of Prostate Cancer Detection, Biopsy Indication Rates, and Positive Predictive Value (PPV)

Screening pathways incorporating MRI were associated with a reduced number of clinically insignificant disease (A) and biopsies (B); moreover, they also outperformed PSA-only strategies in terms of PPV for clinically significant prostate cancer detection (C). MRI was applied as a sequential screening tool (after PSA-prescreen), with a Prostate Imaging Reporting and Data System score of 3 or higher as a cutoff for biopsy indication. CDR indicates cancer detection rate; OR, odds ratio.

Figure 3.. Performance of Magnetic Resonance Imaging (MRI) With a Prostate Imaging Reporting and Data System (PI-RADS) Score of 4 or Higher as a Cutoff for Biopsy Indication

Elevating the PI-RADS cutoff to 4 for the indication of biopsy was associated with lower biopsy rates (B) and less insignificant prostate cancers found (A) compared with prostate-specific antigen (PSA). Moreover, it enhanced the positive predictive value (PPV) for significant disease detection (C). MRI was applied as a sequential screening tool (after PSA prescreening) in this analysis. CDR indicates cancer detection rate; OR, odds ratio.