# GUIDELINE OBJECTIVES
To make recommendations with respect to: 1. a) The use of multiparametric magnetic resonance imaging (MPMRI) in patients with an elevated risk of clinically significant prostate cancer (CSPCa) who are biopsy naive, b) The use of MPMRI-targeted biopsy plus transrectal ultrasound systematic biopsy (TRUS-SB) or MPMRI-TB alone for biopsy-naive patients who have undergone MPMRI;
- a) The use of MPMRI in patients with an elevated risk of CSPCa who have had a prior negative TRUS-SB for any prostate cancer, b) The use of MPMRI-TB plus TRUS-SB or MPMRI-TB alone for patients who have had a prior negative TRUS-SB defined as no prostate cancer on biopsy of any grade group;
- The minimum acceptable standards in the acquisition, interpretation and reporting of MPMRI and the minimal acceptable standards for performance of MPMRI-TB.

# TARGET POPULATION
Patients with an elevated risk of CSPCa (defined as International Society of Urologic Pathology  Grade Group  2), as estimated by available clinical information and tools such as risk calculators and nomograms, of who are A) biopsy naive or B) have had a prior negative TRUS-SB defined as no prostate cancer on biopsy of any grade group.

# INTENDED USERS
Radiologists, oncologists, urologists, and other clinicians who provide care for patients defined by the target population.

# RECOMMENDATIONS Recommendation 1 (Recommendation to use the diagnostic tool)
For biopsy-naive patients at elevated risk of CSPCa:
- MPMRI is recommended prior to biopsy in patients who are candidates for curative management with suspected clinically localized prostate cancer.
- If the MPMRI is positive, MPMRI-TB and TRUS-SB should be performed together to maximize detection of CSPCa.
- If the MPMRI is negative, consider forgoing any biopsy after discussion of the risks and benefits with the patient as part of shared decision making and ongoing followup. Qualifying Statements for Recommendation 1 - Between 8% and 24% of patients with CSPCa may be missed by a negative MPMRI. For this reason, patients should be made aware of the risks and benefits of biopsy avoidance when MPMRI is negative. - MPMRI should only be performed if there is availability of high-quality MPMRI interpretation and operators with experience performing targeted biopsies (see Recommendation 3). - Due to the limited availability, MPMRI is recommended only for patients where there is intent of curative management should the biopsy be positive for CSPCa.

# Recommendation 2 (Recommendation to use the diagnostic tool)
In patients who had a prior negative TRUS-SB and demonstrate a high risk of having CSPCa in whom curative management is being considered:
- MPMRI should be performed,
- If the MPMRI is positive, targeted biopsy should be performed. Concomitant TRUS-SB can be considered depending on the patients risk profile and time since prior TRUS-SB biopsy, - If the MPMRI is negative, consider forgoing a TRUS-SB only after discussion of the risks and benefits with the patient as part of shared decision making and ongoing follow-up. Qualifying Statements for Recommendation 2 - Prior negative TRUS-SB is defined as no cancer of any grade group on prior biopsy.
- MPMRI should only be performed if there is availability of high-quality MPMRI interpretation and operators with experience performing targeted biopsies (see Recommendation 3). - Due to the limited availability, MPMRI is recommended only for patients where there is intent of curative treatment in the case of a positive biopsy.