The Rapid Assessment for Prostate Imaging and Diagnosis (RAPID) pathway was introduced in UK urology centres to streamline prostate cancer diagnosis using an MRI-directed approach. Men with elevated PSA undergo upfront multiparametric MRI (mpMRI), and biopsy is reserved for those with suspicious lesions (PI-RADS/Likert 4–5) or equivocal lesions (score 3) with a PSA density (PSAD) ≥0.12 ng/ml². Patients with negative MRI findings or negative biopsies are discharged to primary care with annual PSA monitoring and individualised re-referral thresholds based on PSAD. Previous studies demonstrated that MRI-directed pathways improve detection of clinically significant prostate cancer (Grade Group [GG] ≥2), reduce overdiagnosis of GG1 disease, and substantially decrease unnecessary biopsies. However, long-term outcomes following discharge after negative investigations remained uncertain. This study represents the largest and most comprehensive evaluation of medium-term outcomes in an MRI-based diagnostic pathway, including over 1,200 patients with risk-stratified follow-up using PSAD. At five years, fewer than 8% of discharged patients were diagnosed with GG≥2 prostate cancer, approximately 4% developed GG≥3 disease, and only 5% required treatment. Importantly, no patients developed metastatic disease or died from prostate cancer. Detection of low-risk GG1 cancer remained below 1%. The RAPID pathway also achieved substantial biopsy avoidance. Nearly half of patients avoided biopsy at initial assessment, and approximately 40% remained biopsy-free after five years. This higher biopsy avoidance rate compared with landmark trials was largely attributable to the use of PSAD to safely defer biopsy in men with equivocal MRI findings. Notably, age, PSAD, atypical small acinar proliferation (ASAP), and high-grade prostatic intraepithelial neoplasia (HGPIN) were not independent predictors of subsequent clinically significant cancer. These findings suggest that men with ASAP or HGPIN may be followed similarly to other patients in the MRI era. Overall, the RAPID pathway appears to be a safe and effective strategy for biopsy triage, reducing unnecessary procedures while maintaining excellent oncological outcomes at five-year follow-up.
Five-year Outcomes for Men after Negative Magnetic Resonance Imaging (MRI) or Negative Biopsy in the RAPID MRI-directed Prostate Cancer Diagnostic Pathway.
Ng CPY, Light A, Eragamreddy SK, et al.
EUROPEAN UROLOGY
2026;89(6):532–40.
