Upfront Biparametric MRI for Prostate Cancer Screening: Experience in 618 Korean Men Outside of a Clinical Trial...

Background: Literature supporting MRI for upfront prostate cancer screening in lieu of a traditional PSA-triggered strategy has been performed primarily within clinical trial settings in North American and European populations. Objective: To describe a single center's experience in performing upfront MRI for PCa screening in Korean men outside of a clinical trial setting. Methods: This retrospective study included 618 asymptomatic Korean men (median age, 61 years) who voluntarily underwent prostate biparametric MRI (bpMRI) from June 2024 to April 2026 as part of a health check-up program. Examinees lacked prior PSA testing and underwent such testing during the same visit as the bpMRI examination. Examinees assessed as PI-RADS ≥3 underwent consultation for biopsy. Outcomes were compared with a simulated PSA-triggered pathway, presuming bpMRI was performed only in examinees with PSA >3.0 ng/mL. Sensitivity analysis was performed in the subset of examinees who would have been eligible for the PROSA randomized trial comparing upfront-MRI and PSA-triggered screening (i.e., men 49-69 years old or ≥40 years old with a prostate cancer family history). Results: The 618 examinees had a median PSA of 0.98 ng/mL. A total of 535/618 (86.6%) examinees were assessed as PI-RADS 1 or 2, none of whom underwent biopsy. A total of 83/618 (13.4%) examinees were assessed as PI-RADS ≥3, 66/618 (10.7%) underwent biopsy, and 9/618 (1.5%) were diagnosed with clinically significant prostate cancer (csPCa). Sixty-two examinees, and eight of nine examinees with csPCa, had PSA >3.0 ng/mL. A simulated PSA-triggered pathway would have avoided 90.0% (556/618) of bpMRI examinations, 69.9% (58/83) of biopsy consultations, and 70.2% (40/57) of performed biopsies without csPCa, at expense of missing one examinee with csPCa. In the PROSA-eligible subset (n=442), the PSA-triggered pathway would have avoided 89.4% (395/442) of bpMRI examinations, 68.2% (45/66) of biopsy consultations, and 66.0% (31/47) of performed biopsies without csPCa, without missing any of five cases of csPCa. Conclusion: The findings indicate inefficiency of the upfront-MRI pathway in Korean men undergoing general health evaluations and support continued use of conventional PSA-gating screening in this population. Clinical Impact: Population-level differences should be carefully considered before extrapolating trial results to other settings.