Prostate cancer screening with MRI: insights from the ESUR Prostate MRI Working Group

Prostate-specific antigen (PSA)-based screening for prostate cancer (PCa) remains controversial due to uncertain long-term benefits, overdiagnosis, and overtreatment of indolent disease. Magnetic resonance imaging (MRI) has transformed the diagnostic pathway of PCa and is increasingly explored as a screening tool. This special report from the ESUR Prostate MRI Working Group provides an overview of current evidence and insights into the potential role of MRI in PCa screening. MRI-based screening strategies appear to improve detection of clinically significant PCa while reducing unnecessary biopsies and diagnoses of non-significant disease, though long-term outcome data, including mortality impact and interval cancer rates, remain limited. Biparametric MRI is particularly suited for screening due to its shorter acquisition time, reduced operational complexity, and lower costs compared with multiparametric MRI. Two main implementation approaches have emerged: MRI-first pathways, which maximise detection but require substantial resources, and risk-stratified strategies, in which MRI is used after initial assessment (e.g. PSA), potentially offering greater feasibility and cost-effectiveness. Evidence from large trials supports integrating MRI into screening pathways, particularly as a reflex test after PSA screening, although uncertainties remain regarding optimal protocols, interpretation thresholds, follow-up strategies, and long-term outcomes. Key barriers include limited MRI capacity, economic considerations, and the need for standardisation and quality assurance. Advances in artificial intelligence may further enhance efficiency. Overall, MRI has the potential to improve the balance between benefits and harms in PCa screening, but further evidence is required to define its optimal implementation. KEY POINTS: Question Can prostate MRI be effectively integrated into population-based prostate cancer screening pathways? Findings MRI-based screening improves detection of csPCa while reducing unnecessary biopsies; biparametric MRI should be the protocol of choice to enhance feasibility, although optimal implementation and long-term outcomes remain uncertain. Clinical relevance MRI may overcome key limitations of PSA-based screening by enhancing the detection of clinically significant prostate cancer while reducing harms such as overdiagnosis and unnecessary biopsies.