Objectives: To evaluate the effect of pre-biopsy MRI on cancer diagnostic times, and to report MRI-directed pathology outcomes.

Methods: 1483 patients were referred with suspicion of prostate cancer during a 30-month period. Upfront MRI was performed in 745 patients: 332 MRIs in 15 months prior to dedicated scanning slots (group 1), and 413 in 15 months post-introduction (group 2). A further 88 patients had initial MRI following clinical assessment. Transrectal (TR) or transperineal (TP) was performed, with MRI/US-fusion for MRI targets. Clinically significant cancer (csPCa) was defined as Gleason ≥3+4. Negative MRIs were defined as no suspicious lesion identified, herein, per-case clinical decisions were taken to biopsy/not.

Results: 484/833 (58.1%) of MRIs were negative, with 44.4% of patients avoiding biopsy due to negative or low suspicion mpMRI. 37.4% of negative MRI patients had initial or subsequent biopsy with NPV of 92.8% and 98.3% for Gleason ≥3+4 and ≥4+3. Overall prostate cancer prevalence was 34.3%, with 24.6% having csPCa. In 323 MRI-positive cases, any cancer was present in 78.9% and csPCa in 60.4%.

1232/1483 (83.1%) patients completed all diagnostic tests within 28-days. Upfront MRI patients met this standard in 621/833 (74.5%), improving from 66.9% to 81.1% with reserved slots (group 2) with a reduced diagnostic time from median 25.5 to 20.9 days. Biopsy scheduling delayed the pathway in 69.7%, with MRI responsible in 22.3%, reducing to 10.3% in group 2. TP biopsies met the 28-day standard in significantly less cases (29.7%), compared to TR (67.4%), p<0.0001.

Conclusion: Reserved MRI slots reduces time-to-diagnosis, and upfront MRI safely avoids biopsy in a significant proportion of men, whilst maintaining expected csPCa detection rates.