Emerging Concepts and Recommendations for MRI in Prostate Cancer Screening
In a recent literature review, researchers offered insights on current considerations with prostate MRI and discussed keys to effective use of the modality in screening for prostate cancer.
Should men with indeterminate magnetic resonance imaging (MRI) results refrain from getting a subsequent biopsy for prostate cancer (PCa)? Is staged MRI interpretation a viable option in PCa screening? Should MRI be a first-line option in the screening of patients for PCa?
In a new review, recently published in the American Journal of Roentgenology, researchers discussed the aforementioned questions and more on prostate MRI, and offered recommendations to optimize the use of the modality.1
Here are seven key takeaways.
1. Should MRI be utilized as a first-line screening modality? Emphasizing that nearly 50 percent of clinically significant prostate cancer (csPCa) is missed with a prostate-specific antigen (PSA) level threshold of 3 ng/mL for proceeding to MRI, the review authors maintained that first-line screening with MRI may have a significant impact in diagnosing these missed cases.1
However, noting the high costs of MRI and increased likelihood of indeterminate results, particularly in cases involving younger patients, the review authors posited that an MRI-only approach to PCa screening is impractical in clinical practice.
Here one can see the use of a deep learning model, which correctly predicted and established the borders for a prostate cancer (PCa) lesion in a patient with clinically significant PCa (csPCa). Artificial intelligence (AI) can automate time-consuming elements of prostate MRI interpretation, facilitate real-time adaptation in imaging and bolster detection in suspicious cases, according to the authors of a new literature review on prostate MRI. (Images courtesy of Insights into Imaging.)
“Performing MRI on a large scale without prior risk stratification can yield a high proportion of negative results and associated unnecessary costs,” noted lead review author Ivo G. Schoots, M.D., who is affiliated with the Department of Radiology and Nuclear Medicine at Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues.
2. What role does abbreviated MRI play in PCa screening? For optimal cost-effectiveness and benefit-to-harm ratios, the study authors maintained that a combination of abbreviated MRI and higher PSA biopsy thresholds may enhance workflow in population-based PCa screening.
3. Can artificial intelligence (AI) have an impact? In addition to acceleration of MRI scan times, AI can automate time-consuming elements of prostate MRI interpretation, facilitate real-time adaptation in imaging and bolster detection in suspicious cases, according to the review authors. While cautioning that calibration and validation of AI models are needed prior to being utilized in clinical practice, the researchers said there is significant potential for increased standardization of prostate MRI assessment.
“Deep-learning computer-aided detection algorithms can evaluate images to assist radiologists in identifying suspicious lesions, segmenting the prostate, and assigning suspicion scores for detected lesions,” noted Schoots and colleagues. “These tasks can enhance efficiency, accuracy, and consistency of interpretation, especially for less-experienced readers.”
(Editor’s note: For additional content on prostate cancer imaging, click here.)
4. Should biopsies be deferred in PI-RADS 3 cases in the screening setting? While noting that multiplanar and contrast-enhanced prostate MRI sequences can enhance lesion characterization in PI-RADS 3 cases, the review authors pointed out that subsequent biopsies after PI-RADS 3 assessments yield grade group (GG) scores > 2 20 percent of the time.1
In the screening setting, the researchers said management decisions with respect to PI-RADS 3 evaluations should “lean towards biopsy avoidance with return to screening.” They maintained that factors such as PSA density and patient preference are more effective guideposts in this patient population.
5. Is there merit to staged MRI assessment? Citing the recent ReIMAGINE study, the review authors noted the combination of preliminary axial T2-weighted MRI and high B-value diffusion-weighted imaging (DWI) for initial PCa screening.2 Any cases involving a suspicious lesion would receive subsequent PI-RADS assessment with multiplanar MRI and apparent diffusion coefficient (ADC) mapping, according to the researchers.
The review authors said this approach led to 52 percent and 90 percent detection rates of GG > 2 PCa after initial imaging and the second round of imaging respectively.2
6. Do not report non-diagnostic or low-quality MRIs scans as “indeterminate” for PCa. Particularly when it comes to ruling out csPCa, the review authors emphasized the use of consistent thresholds for non-diagnostic or low-quality scans in order to reduce diagnostic errors.
7. Strive for improved efficiency and consistency with MRI acquisition and interpretation. For PCa screening, the researchers advocated standard use of patient preparations as well as consistent application of PI-RADS compliant imaging parameters. They also suggested that limiting scans to axial or 3D sequences can reduce MRI scan times in PCa screening.
“Limit scanning times to 5 to 10 minutes for higher throughput, adoption, acceptance, and cost reduction,” noted Schoots and colleagues.
References
1. Schoots IG, Haider MA, Punwani S, Padhani AR. MRI in prostate cancer screening: a review and recommendations, from the AJR special series on screening. AJR Am J Roentgenol. 2025. https://ajronline.org/doi/10.2214/AJR.24.32588 . Published February 19, 2025. Accessed February 23, 2025.
2. Marsden T, Lomas DJ, McCartan N, et al. ReIMAGINE Prostate Cancer Screening Study: protocol for a single-centre feasibility study inviting men for prostate cancer screening using MRI. BMJ Open. 2021;11(9):e048144. doi: 10.1136/bmjopen-2020-048144 .
