MRI in Prostate Cancer Screening: A Review and Recommendations, From the AJR Special Series on Screening

Traditional PSA-based screening for prostate cancer (PCa) is challenged by an unfavorable benefit-to-harm ratio from underdiagnosis of clinically significant cancers, overdiagnosis of indolent cancers, and unnecessary biopsies, despite demonstrated reductions in PCa-associated mortality. Inclusion of MRI in screening algorithms helps address these limitations by improving risk stratification of men suspected of having PCa and by enabling targeted biopsies. The impact of MRI-based strategies on screening's benefit-to-harm ratio can be objectively assessed using ratios reflecting clinically significant cancers detected, indolent cancers detected, unproductive biopsies, and avoided biopsies. Of two overarching MRI-based screening strategies (sequential MRI after PSA testing and MRI alone), the sequential strategy is favored as a balanced and scalable approach. This Special Series Review provides a detailed analysis of the role of MRI in PCa screening, targeted to radiologists. Recommendations are provided for optimizing the use of MRI in PCa screening, including individualized risk assessments, tailored protocols, quality assurance for ensuring reliable and reproducible results, and consideration of new screening-specific scoring systems and biopsy thresholds. Ultimately, successful integration of MRI in PCa screening will require radiologists to actively engage in refining protocols, standardizing interpretations, and adopting emerging technologies. Such efforts will help maximize benefits while minimizing harms, enabling wider acceptance of PCa screening.