The impact of 5-alpha reductase inhibitors on multiparametric MRI diagnostic performance and prostate-specific antigen density triage: A systematic review
In brief
MRI sensitivity stayed near 94% for cancer detection in 5-alpha reductase inhibitor users
Across seven observational studies, MRI sensitivity for clinically significant prostate cancer was 93.8% in men taking 5-alpha reductase inhibitors, close to 96.1% in other men. A prostate-specific antigen density cutoff avoided biopsy in more men taking the drugs, with similar missed-cancer rates, but one lesion-level study found weaker detection in the prostate's peripheral zone; prospective validation is needed.
- Journal
- BJUI compass (Q1)
- Published
- 30 October 2026
- Study design
- Systematic review of cohort studies
- Evidence level
- Level 2, Moderate (CEBM 2a)
- Authors
- Gregory Harrison, Bogdan Toia, Anju Sahdev, Prabhakar Rajan, Benjamin W Lamb
- PMID
- 42966989
- DOI
- 10.1002/bco2.70294
Why clinicians should know about it
- Picked for Urology (paper of the day, 3 November 2026): Systematic review informs prostate MRI diagnosis and biopsy triage
Abstract
OBJECTIVES: To evaluate the impact of 5-alpha reductase inhibitor (5-ARI) exposure on multiparametric MRI (mpMRI) diagnostic performance for clinically significant prostate cancer (csPCa) and to assess whether standard prostate-specific antigen density (PSAD)-gated biopsy thresholds remain safe in this population. SUBJECTS/PATIENTS AND METHODS: A systematic review followed PRISMA 2020 (PROSPERO: CRD420251050507). PubMed/MEDLINE, EMBASE and the Cochrane Library were searched from January 2015 to December 2024. Eligible studies reported PI-RADS, PSAD or lesion-level apparent diffusion coefficient (ADC) data by exposure status, biopsy-verified csPCa (ISUP grade group ≥2) and an unexposed comparator (≥100 patients). Risk of bias was assessed using QUADAS-2 and ROBINS-I; heterogeneity precluded meta-analysis. RESULTS: Seven comparative studies met inclusion criteria. Patient-level csPCa diagnostic accuracy was largely maintained: Sensitivity at a PI-RADS ≥3 threshold was 93.8% in exposed versus 96.1% in unexposed men, csPCa detection was 39.1% versus 39.3% (p = 0.9), and 5-ARI exposure was not an independent negative predictor of detection. On blinded matched review, peripheral zone lesion ADC was higher in exposed men (869 vs. 765 mm2/s, p = 0.04) with lower conspicuity (1.59 vs. 1.78, p = 0.03); that cohort also reported lower adjusted per-lesion yield (OR 0.32, 95% CI 0.18-0.57), confined to the peripheral zone. A PSAD threshold of >0.15 ng/ml/cc avoided biopsy in 37.0% of exposed versus 30.3% of unexposed men, with missed csPCa in 12.3% and 11.0%, respectively. CONCLUSION: Across seven heterogeneous observational studies, patient-level mpMRI performance for csPCa appears largely preserved in men receiving 5-ARIs, though this lacks pooled support and was not reproduced in the one lesion-level, zone-stratified analysis. Standard PSAD-gated thresholds, evidenced by a single cohort, may perform comparably across populations. Prospective validation is required.
Abstract as published, via PubMed.
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