The ideal prostate cancer diagnostic pathway would maximise detection of clinically-significant prostate cancer (csPCa) while avoiding unnecessary biopsies and other investigations. The introduction of pre-biopsy MRI has done much to aid this goal. However, referrals into the image-based diagnostic pathway still depends on prostate-specific antigen (PSA) testing performed in primary care and interpreted using referral guidelines. In the UK, the National Institute for Health and Care Excellence (NICE) only provides guidance on PSA thresholds for men aged 50-69 years (PSA ≥3.0 ng/mL) [1]. For other age groups, PSA thresholds are set by regional cancer networks without any national consensus. Here we explored if different regional guidelines impacted csPCa detection in modern image-based pathways.