Balancing the benefits and harms of MRI-directed biopsy pathways

• Before a prostate biopsy, the likely benefits and the harms emanating from true and false test MRI results need to be balanced. Prioritizing patients' preferences and their tolerance to potential harms are essential to assess.• The decision curve analysis method is an analytical framework where the net clinical benefit is plotted against a range of risk thresholds of having important cancers, helping patients and their physicians to decide between cancer averse (important cancers being detected) and biopsy averse (biopsies avoided) strategies.• The decision curve analysis method showed that the incorporation of clinical risk factors with MRI findings optimizes biopsy outcomes over a range of clinically relevant risk thresholds, compared to other biopsy strategies.