ArticleEuropean radiology2022
Risk-based MRI-directed diagnostic pathway outperforms non-risk-based pathways in suspected prostate cancer biopsy-naïve men: a large cohort validation study.
Article in European radiology, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 9 papers, 1 of them a synthesis that pooled it.
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Who cites it
9 citing papers in PubMed, 1 synthesis or guideline pooled it, 16 citations in OpenAlex.
- Magnetic Resonance Imaging, Clinical, and Biopsy Findings in Suspected Prostate Cancer: A Systematic Review and Meta-Analysis.JAMA network open · 2024Pooled it
- Natural History of PI-RADS 3 Lesions on Serial Prostate mpMRI.The Prostate · 2026Article
- Increasing and more consistent use of pre-biopsy MRI in prostate cancer diagnosis: insights from a population-based study in the Netherlands.Insights into imaging · 2026Article
- Evolution of the prostate cancer diagnostic paradigm: integrated evidence and clinical pathways from targeted biopsy to biopsy-free strategy.Frontiers in oncology · 2026Review
- A multi-center study: development and validation of a BpMRI focused model in transition zone PI-RADS 3 and 4 lesions to detect clinically significant prostate cancer.Abdominal radiology (New York) · 2025Article
- Risk stratification of prostate cancer with MRI and prostate-specific antigen density-based tool for personalized decision making.The British journal of radiology · 2024Article
- PI-RADS 3 lesions: a critical review and discussion of how to improve management.Abdominal radiology (New York) · 2023Review
- Article
- Balancing the benefits and harms of MRI-directed biopsy pathways.European radiology · 2022Article
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Authors and funding
5 authors at 5 institutions in 2 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectivesTo investigate and compare the performance of different proposed diagnostic pathways in a cohort of biopsy-naïve men at risk for prostate cancer (PCa), in terms of biopsy avoidance, accurate diagnosis of clinically significant prostate cancer (csPCa), and reduction in overdiagnosis of clinically insignificant cancer (cisPCa), with particular focus on a recently suggested "risk-based" MRI-directed diagnostic pathway.
methodsSingle-center, retrospective cohort study, including 499 biopsy-naïve men at risk for PCa. All men underwent PI-RADS-compliant prostate MRI, transrectal ultrasound fusion-guided targeted (TBx), and systematic biopsy (SBx). Five diagnostic pathways were retrospectively evaluated and compared for. Outcome measures were biopsy avoidance, combined with missed csPCa and detected cisPCa. csPCa and cisPCa were defined as ISUP grade group ≥ 2 and grade = 1, respectively. Chi-square test was used for statistical analysis. Decision curve analyses were used to compare the benefits of the pathways across a range of biopsy thresholds.
resultsThe prevalence (detection-focused [reference] pathway) of csPCa and cisPCa was 52.9% (264/499) and 23.0% (115/499). MRI-focused pathway (no biopsy in PI-RADS 1-2 men) did not significantly reduce ISUP ≥ 2 cancer detection (52.1% (260/499); p = 0.13), but significantly reduced ISUP 1 cancers diagnosed (20.6% (103/499); p < 0.01), and biopsy avoidance was 11.8% (59/499). The risk-based MRI-directed pathway (no biopsy in low-risk PI-RADS 1-3 men) resulted in a small reduction of ISUP ≥ 2 diagnosed (51.7% (258/499); p = 0.04), however non-significant when compared to MRI-focused pathway (p = 0.625). Moreover, the risk-based pathway further reduced detection of ISUP 1 (18.6% (93/499); p < 0.01), and biopsy avoidance was 19.2% (96/499). Decision curve analysis showed maximized net benefit of the risk-based pathway, for the range of threshold probabilities between 6.25 and 65%.
conclusionThe risk-based MRI-directed pathway for prostate cancer diagnosis was optimal in balancing accurate diagnosis, reducing overdiagnosis, and maximizing biopsy avoidance. This substantial evidence should inform guideline recommendations towards using "risk-based" MRI-directed biopsy decisions in biopsy-naïve men at risk of significant prostate cancer. KEY POINTS: • Our study recognizes the added value of prostate MRI and MR-targeted biopsies in order to propose clinical diagnostic pathways for prostate cancer, towards maximizing the potential avoidance of unnecessary biopsies, while maintaining optimal detection rate of clinically significant prostate cancer. • The risk-based MRI-directed pathway incorporates risk factors such as PSA density, digital rectal examination, and family history to further refine the initial stratification of patients based on PI-RADS scores. • In this study, the risk-based pathway had the most optimal performance in terms of combination of outcomes, with the highest rate of biopsy avoidance (19.2%), while keeping a high detection rate of clinically significant prostate cancer (51.7%), when compared to the reference standard (52.9%).
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