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Primary MRI versus PSA-gated scans in Prostate Cancer Screening – how ready is it for mainstream implementation?

Prostate Cancer and Prostatic Diseases (2025)Cite this article

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Abstract

Background

Abnormal PSA test results leading to MRI scans is mainstream practice in prostate cancer diagnosis. However, a similar algorithm may lead to under-detection of clinically significant prostate cancer (csPCa) in disease screening. We compare cancer detection rates (CDR) in screening with MRI prostate only (‘primary’ MRI) compared to MRI scans triggered by abnormal serum PSA levels (‘PSA-gated’ MRI).

Methods

Pubmed, Embase, Web of Science, CENTRAL, Scopus and Google Scholar were searched using key terms of “MRI”, “prostate cancer”, and “screening” from 01/1/2000–20/4/2024. We included studies investigating the general adult male population not otherwise risk stratified, and extracted outcomes of CDR for csPCa (ISUP Grade Group ≥ 2) and clinically insignificant prostate cancer (ciPCa) (ISUP Grade Group 1), and biopsy rate.

Results

17 studies were included for final analysis. When including all studies, primary MRI had a higher CDR compared to PSA-gated MRI for all prostate cancer (8.49% vs. 1.88%, p = 0.0223) and csPCa (5.93% vs. 1.15%, p = 0.0180) detection respectively. There was no statistically significant difference in CDR for ciPCa between both groups. In studies directly comparing primary and PSA-gated MRI, primary MRI demonstrated higher odds of detection for all prostate cancer (OR 2.77, 95%CI: 1.71–4.49), csPCa (OR 2.32, 95%CI: 1.37–3.96) and ciPCa (OR 3.11, 95%CI: 1.08–8.97). Limitations include verification bias and heterogeneity between studies.

Conclusions

Primary MRI screening demonstrated higher CDR for csPCa than PSA-gated MRI screening triggered at PSA thresholds of 3-4 ng/ml. There is also higher CDR of ciPCa and adoption of needle biopsies. More granular cost-effectiveness outcomes are required before mainstream implementation is possible.

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Authors and Affiliations

  1. Department of Urology, Sengkang General Hospital, Singapore, Singapore

    Jun Heng Lim, Christopher Yong-Zyn Lo, Jeremy Yong Jie Tay, Raj Vikesh Tiwari, Thomas Kong Ngai Chan & Lui Shiong Lee

  2. Department of Biostatistics, Duke-NUS Medical School, Singapore, Singapore

    Rehena Sultana

  3. Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore

    Melvin Chua Lee Kiang

  4. Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore

    Ravindran Kanesvaran

  5. Department of Radiology, Sengkang General Hospital, Singapore, Singapore

    Shawn Kok Shi Xian & Min On Tan

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Contributions

LJH: Conceptualization, Methodology, Investigation, Data curation, Writing - Original Draft, Writing - Review & Editing, Visualization. CYZL: Conceptualization, Methodology, Investigation, Resources, Data curation, Writing - Original Draft, Writing - Review & Editing, Visualization. RS: Conceptualization, Methodology, Software, Formal analysis, Visualization. JYJT: Conceptualization, Writing - Original Draft. RVT: Conceptualization, Writing - Original Draft. TKNC: Conceptualization, Writing - Original Draft. MCLK: Writing - Original Draft. RK: Writing - Original Draft. SKSX: Writing - Original Draft. TMO: Writing - Original Draft. LLS: Conceptualization, Methodology, Writing - Original Draft, Writing - Review & Editing, Supervision, Project administration

Corresponding author

Correspondence to Lui Shiong Lee.

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The authors declare no competing interests.

Ethics

The data used in our analysis is publicly available from published studies. As such, no institutional review board (IRB) approval was necessary. This study was not supported by any sources of funding. All authors have no disclosures to report.

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MRI-based screening can improve cancer detection.

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Lim, J.H., Lo, C.YZ., Sultana, R. et al. Primary MRI versus PSA-gated scans in Prostate Cancer Screening – how ready is it for mainstream implementation?. Prostate Cancer Prostatic Dis (2025). https://doi.org/10.1038/s41391-025-01048-6

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