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.