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.

Centre for Translational Medicine Semmelweis University Budapest Hungary

Comprehensive Cancer Center Department of Urology Medical University of Vienna Vienna Austria

Department of Biomedical Informatics College of Medicine Konyang University Daejeon Republic of Korea

Department of Radiology and Nuclear Medicine Erasmus MC Cancer Institute University Medical Centre Rotterdam the Netherlands

Department of Radiology Netherlands Cancer Institute Amsterdam the Netherlands

Department of Urology 2nd Faculty of Medicine Charles University Prague Czech Republic

Department of Urology Assistance Publique des Hôpitaux de Marseille North Academic Hospital Marseille France

Department of Urology Erasmus MC Rotterdam the Netherlands

Department of Urology Hospital Universitario La Paz Madrid Spain

Department of Urology Jagiellonian University Medical College Krakow Poland

Department of Urology La Croix du Sud Hospital Quint Fonsegrives France

Department of Urology Medical University of Silesia Zabrze Poland

Department of Urology Semmelweis University Budapest Hungary

Department of Urology St Antonius Hospital Utrecht the Netherlands

Department of Urology University of Duisburg Essen and German Cancer Consortium University Hospital Essen Essen Germany

Department of Urology University of Texas Southwestern Medical Center Dallas

Department of Urology Weill Cornell Medical College New York New York

Department of Urology Yale School of Medicine New Haven Connecticut

Division of Surgery and Interventional Science University College London London England

Division of Urology Department of Special Surgery Jordan University Hospital The University of Jordan Amman Jordan

Hourani Center for Applied Scientific Research Al Ahliyya Amman University Amman Jordan

Institute of Mathematics Department of Stochastics Budapest University of Technology and Economics Budapest Hungary

Karl Landsteiner Institute of Urology and Andrology Vienna Austria

The National Center for Diabetes Endocrinology and Genetics The University of Jordan Amman Jordan

Unit of Urology Urological Research Institute Division of Oncology IRCCS San Raffaele Scientific Institute Vita Salute San Raffaele University Milan Italy

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