Trends and Patterns in Prostate Cancer Diagnostics During the Era of MRI Implementation – Real-world Evidence From a Population-based Study in the Stockholm Region, Sweden 2010–2023

Implementation of pre-biopsy magnetic resonance imaging in prostate cancer diagnostics reduced unnecessary biopsies and low-grade cancer detection, while more than doubling the detection of clinically significant cancers, demonstrating improved precision of diagnostics at a population level. Pre-biopsy magnetic resonance imaging (MRI) is recommended in prostate cancer diagnostics, but its impact on testing patterns and diagnostic outcomes on a population-level remains unclear. Using the Stockholm Prostate Cancer Diagnostics Register, we conducted a population-based study of men aged ≥40 yr without prior prostate cancer during 2010–2023. We described the trends in prostate-specific antigen (PSA) testing, the proportion of men with PSA ≥3 ng/ml undergoing further testing (MRI and/or biopsy), and the distribution of biopsy outcomes. PSA testing was stable over time, with greater uptake observed in older men: in 2023, 14-yr prevalence was 76% in men aged 60–69 yr, and 84% in both those aged 70–79 and ≥80 yr. Among men with PSA ≥3 ng/ml, MRI within 1 yr increased from 3% in 2010 to 30% in 2023, while the proportion undergoing prostate biopsy declined from 23% to 16% (relative risk RR: 0.71; 95% confidence interval CI: 0.69–0.73). By 2023, 83% of biopsied men had a pre-biopsy MRI. Over the study period, biopsy outcomes improved: detection of International Society of Urological Pathology ISUP grade group GG ≥2 cancers more than doubled (RR: 2.12; 95% CI: 1.99–2.27), whereas both benign biopsies (RR: 0.66; 95% CI: 0.62–0.69) and ISUP GG 1 (RR: 0.61; 95% CI: 0.54–0.69) declined markedly. PSA testing remained prevalent, and pre-biopsy MRI use increased substantially. During this period, detection of significant cancer among biopsied men increased markedly while unnecessary biopsies and low-grade cancer findings decreased. This study provides real-world population-based data that are consistent with a trend toward increased precision in prostate cancer diagnostics in the era of MRI implementation.