Prostate cancer screening continues to develop and improve — and an important part of the screening arsenal is MRI, according to research presented at the European Association of Urology (EAU) 2026 congress in London.
Thirty-year data shared at the meeting confirmed mortality benefits and outlined new strategies to reduce unnecessary imaging, said Tobias Nordström, MD, of the Karolinska Institute in Solna, Sweden, and member of the EAU Scientific Congress office.
“We know that screening can save lives,” he said in a statement from the association. “This [has been] confirmed with 30-year data from the longest running prostate cancer screening trial … [A] a key tool for this is MRI, and we are now seeing research [that shows] how we can make best use of it in real-world, clinical practice.”
The association highlighted four studies that demonstrated the positive evolution of prostate cancer screening.
Gothenburg study
The Gothenburg 1 study began in 1994 and included 20,000 men between the ages of 50 and 64. Half of these participants were invited for prostate-specific antigen (PSA) testing every two years until the age of 70; they were referred directly for systematic biopsy if their PSA was 3 ng/ml or more. The other half of the study participants were not invited for screening. Of the total cohort, 1,711 men in the screening group and 1,373 men in the control group were diagnosed with prostate cancer over the study timeframe.
A team led by Jonas Hugosson, MD, of the University of Gothenburg, found that screening helped to avert one prostate cancer death for every 311 men invited after 15 years, and for every 161 men after 30 years. It also helped to avert one death for every 13 men diagnosed with the disease after 15 years and one death for every six men diagnosed after 30 years.
However, the study did find a higher incidence of prostate cancer in the screening group compared with what would normally be expected.
“This is the longest follow-up of any screening study and shows that the beneficial effect of screening on prostate cancer mortality continues to increase with time,” Hugosson said. “[Yet] it’s also clear that screening detects cancers which would otherwise remain undetected and not be a cause for concern. This overdiagnosis may be due to the diagnostic pathway followed in the study, which has now been [replaced] by the use of MRI and risk-stratification to reduce the number of insignificant cancers identified.”
PRISM screening recommendations
In another presentation, Nikhil Mayor, a doctoral fellow at Imperial College London in the U.K., outlined prostate cancer screening recommendations from the Prostate Imaging Standards for Screening MRI (PRISM) study.
“MRI is key to diagnosing prostate cancer, but there’s no agreement as to how it should be used in population-level screening,” he said. “We hope that the PRISM recommendations, backed by international expert consensus, will be widely adopted so that protocols are standardized for future screening pilots, studies, and programs.”
Mayor and colleagues used the RAND/UCLA Appropriateness Method to generate prostate cancer screening recommendations, with 21 experts in urology, radiology, and pathology from six countries evaluating factors such as screening population, pre-MRI risk stratification, MRI acquisition, interpretation, repeat screening, biopsy considerations, quality assurance and control, and AI.
The experts produced 323 screening recommendation statements, of which 236 (73.1%) achieved consensus. These included the following:
- Offer abbreviated MRI (no T1 or dynamic contrast enhancement, max acquisition time ≤15 min) to men aged 50 to 70 with a life expectancy of more than 10 years, or from age 45 for Black men.
- Use T2 and diffusion-weighted imaging (with apparent diffusion coefficient [ADC] and high b-values) as core sequences.
- Use pre-MRI risk-stratification with PSA testing.
- Stage-gated approach to reporting, where the full biparametric MRI (bpMRI) is only shown if a concordant focal lesion is identified on axial T2-weighted and high b-value imaging, should be used to reduce biopsy rates and improve screening MRI’s positive predictive value.
- Men with modified PI-RADS scores ≥ 4 should undergo biopsy.
- The optimal interval for repeat screening should be risk-stratified according to patient, PSA, and MRI characteristics.
- AI is not yet recommended for standalone clinical decision-making.
Risk-based screening approach reduces MRI referrals
MRI is important for prostate cancer screening, but its use should be appropriate, according to a team led by Meike van Harten, a doctoral candidate at Erasmus MC Cancer Institute, University Medical Centre in Rotterdam, the Netherlands.
Van Harten and colleagues found that data from the PRostate cancer Awareness and Initiative for Screening in the European Union (PRAISE-U) study showed that MRI referrals can be reduced by 40% to 60% when clinicians use risk stratification tools along with PSA test results.
Overall, van Harten and colleagues reported that all risk stratification methods (i.e., the Rotterdam Prostate Cancer Risk calculator [RPCRC] and prostate volume assessment methods such as digital rectal examination, transrectal ultrasound, and transabdominal ultrasound) reduced the absolute number of MRI referrals, but centers that use the RPCRC with transrectal ultrasound reported the greatest reduction in unnecessary MRIs.
“The implementation of population-based prostate cancer screening programs in Europe could result in around five million men being referred for MRI scans solely based on PSA,” she said in the association statement. “We need to find ways to reduce demand on MRI so that fewer men have unnecessary tests and those that need it get timely access to a diagnosis.”
Stockholm weighs in
In a fourth study, Ugo Falagario, MD, and colleagues found that an advanced testing strategy designed to detect aggressive prostate cancers reduced the need for MRI exams. The strategy — a blood test called Stockholm3 — uses an algorithm that combines protein and genetic biomarkers with clinical information. A group of 17,801 men was invited to prostate cancer screening in 2023, and 30,556 in 2024; of these, 13,733 men between the ages of 50 and 52 were included in the study. The key findings were that administering the Stockholm3 test before MR imaging in men with PSA 2 ng/ml or more led to 67% fewer MRI scans.
“Since rolling out prostate cancer screening programs across most Swedish regions, the call on MRI scans is very high,” he said. “We now demonstrate [that Stockholm3] can be implemented in population-based organized prostate testing to identify only those with potentially higher-risk cancers who require a referral for an MRI scan … [which can] significantly reduce the demand on imaging services.”
The bottom line? Taken together, these findings show that prostate cancer screening is becoming progressively more targeted and better tolerated, with evolving tools to concentrate diagnostic resources on men most likely to harbor clinically significant disease, the association noted.