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In general, when there is an increased risk of PCa, systematic random transrectal ultrasound (TRUS) biopsies are performed. The specificity of PSA testing is of limited value, as 70-80% of patients with slight PSA elevation (>4.0 ng/mL) have benign prostatic hyperplasia (BPH) or prostatitis rather than PCa. DRE is affected by considerable inter-observer variability, and is limited to the evaluation of lesions in the posterior and lateral peripheral zone. However, these techniques are being considered of restricted accuracy in PCa detection. doubling time or PSA velocity) are biological signs indicating an increased risk of PCa. Nowadays, an abnormal digital rectal examination (DRE), an elevated PSA level or anomalous changes in PSA level and dynamics (i.e. The improvement in overall life expectancy and the trend to apply lower cut-off levels for the PSA blood level test will further increase the number of men diagnosed with PCa. To a certain extent this can be explained by the introduction of prostate specific antigen (PSA) level measurement, by the development of improved diagnostic imaging and by the improvement in demographic information systems. The past three decades have seen a steep rise in PCa incidence. 1 Presently, one in six men will be diagnosed with PCa at a certain moment in their life. © 2020 International Society for Magnetic Resonance in Medicine.With almost 240,000 new cases and approximately 30,000 deaths in the USA predicted for 2013, prostate cancer (PCa) is the most common non-cutaneous male cancer, and the second cause of cancer-related death. Likert scale MRI-directed biopsy PI-RADS biparametric MRI clinically significant prostate cancer multiparametric MRI prostate cancer. Level of Evidence 1 Technical Efficacy Stage 5. Only then can we be confident in recommending bpMRI as an initial diagnostic approach for prostate cancer diagnosis. These studies should more precisely define patient groups where the benefits and harms of contrast enhancement are aligned to their clinical priorities. There is a requirement for prospective, randomized, or blinded head-to-head, multicenter studies, addressing the noninferiority of biopsy yields prompted by bpMRI and multiparametric MRI approaches. Robust prospectively acquired data for bpMRI regarding biopsy avoidance, detection of clinically significant and insignificant cancers, and for increasing the precision of tumor grade and volume are needed. Although systematic reviews and individual studies are broadly supportive of the bpMRI approach, the pathway impacts for men with suspected cancer using the bpMRI approach are still not well documented for clinical practice. It is the balance of these factors weighted against the clinical priorities of patients that determines which patient groups can safely avoid dynamic contrast enhancement. The abandonment of the routine use of contrast medium requires an assessment of the loss of diagnostic power against the gains in operational logistics, costs, time, capacity, and side effects. The benefits and drawbacks of the dynamic contrast-enhanced MRI sequence for prostate cancer diagnosis are increasingly being recognized, with many centers adopting the biparametric (bp) MRI approach as the default initial approach.