how to do a systematic literature review in nursing pdf

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Systematically Reviewing the Literature: Building the Evidence for Health Care Quality

There are important research and non-research reasons to systematically review the literature. This article describes a step-by-step process to systematically review the literature along with links to key resources. An example of a graduate program using systematic literature reviews to link research and quality improvement practices is also provided.

Introduction

Systematic reviews that summarize the available information on a topic are an important part of evidence-based health care. There are both research and non-research reasons for undertaking a literature review. It is important to systematically review the literature when one would like to justify the need for a study, to update personal knowledge and practice, to evaluate current practices, to develop and update guidelines for practice, and to develop work related policies. 1 A systematic review draws upon the best health services research principles and methods to address: What is the state of the evidence on the selected topic? The systematic process enables others to reproduce the methods and to make a rational determination of whether to accept the results of the review. An abundance of articles on systematic reviews exist focusing on different aspects of systematic reviews. 2 – 9 The purpose of this article is to describe a step by step process of systematically reviewing the health care literature and provide links to key resources.

Systematic Review Process: Six Key Steps

Six key steps to systematically review the literature are outlined in Table 1 and discussed here.

Systematic Review Steps

1. Formulate the Question and Refine the Topic

When preparing a topic to conduct a systematic review, it is important to ask at the outset, “What exactly am I looking for?” Hopefully it seems like an obvious step, but explicitly writing a one or two sentence statement of the topic before you begin to search is often overlooked. It is important for several reasons; in particular because, although we usually think we know what we are searching for, in truth our mental image of a topic is often quite fuzzy. The act of writing something concise and intelligible to a reader, even if you are the only one who will read it, clarifies your thoughts and can inspire you to ask key questions. In addition, in subsequent steps of the review process, when you begin to develop a strategy for searching the literature, your topic statement is the ready raw material from which you can extract the key concepts and terminology for your strategies. The medical and related health literature is massive, so the more precise and specific your understanding of your information need, the better your results will be when you search.

2. Search, Retrieve, and Select Relevant Articles

The retrieval tools chosen to search the literature should be determined by the purpose of the search. Questions to ask include: For what and by whom will the information be used? A topical expert or a novice? Am I looking for a simple fact? A comprehensive overview on the topic? Exploration of a new topic? A systematic review? For the purpose of a systematic review of journal research in the area of health care, PubMed or Medline is the most appropriate retrieval tool to start with, however other databases may be useful ( Table 2 ). In particular, Google Scholar allows one to search the same set of articles as PubMed/MEDLINE, in addition to some from other disciplines, but it lacks a number of key advanced search features that a skilled searcher can exploit in PubMed/MEDLINE.

Examples of Electronic Bibliographic Databases Specific to Health Care

Note: These databases may be available through university or hospital library systems.

An effective way to search the literature is to break the topic into different “building blocks.” The building blocks approach is the most systematic and works the best in periodical databases such as PubMed/MEDLINE. The “blocks” in a “building blocks” strategy consist of the key concepts in the search topic. For example, let’s say we are interested in researching about mobile phone-based interventions for monitoring of patient status or disease management. We could break the topic into the following concepts or blocks: 1. Mobile phones, 2. patient monitoring, and 3. Disease management. Gather synonyms and related terms to represent each concept and match to available subject headings in databases that offer them. Organize the resulting concepts into individual queries. Run the queries and examine your results to find relevant items and suggest query modifications to improve your results. Revise and re-run your strategy based on your observations. Repeat this process until you are satisfied or further modifications produce no improvements. For example in Medline, these terms would be used in this search and combined as follows: cellular phone AND (ambulatory monitoring OR disease management), where each of the key word phrases is an official subject heading in the MEDLINE vocabulary. Keep detailed notes on the literature search, as it will need to be reported in the methods section of the systematic review paper. Careful noting of search strategies also allows you to revisit a topic in the future and confidently replicate the same results, with the addition of those subsequently published on your topic.

3. Assess Quality

There is no consensus on the best way to assess study quality. Many quality assessment tools include issues such as: appropriateness of study design to the research objective, risk of bias, generalizability, statistical issues, quality of the intervention, and quality of reporting. Reporting guidelines for most literature types are available at the EQUATOR Network website ( http://www.equator-network.org/ ). These guidelines are a useful starting point; however they should not be used for assessing study quality.

4. Extract Data and Information

Extract information from each eligible article into a standardized format to permit the findings to be summarized. This will involve building one or more tables. When making tables each row should represent an article and each column a variable. Not all of the information that is extracted into the tables will end up in the paper. All of the information that is extracted from the eligible articles will help you obtain an overview of the topic, however you will want to reserve the use of tables in the literature review paper for the more complex information. All tables should be introduced and discussed in the narrative of the literature review. An example of an evidence summary table is presented in Table 3 .

Example of an evidence summary table

Notes: BP = blood pressure, HbA1c = Hemoglobin A1c, Hypo = hypoglycemic, I = Internet, NS = not significant, PDA = personal digital assistant, QOL = quality of life, SMBG = self-monitored blood glucose, SMS = short message service, V = voice

5. Analyze and Synthesize Data and information

The findings from individual studies are analyzed and synthesized so that the overall effectiveness of the intervention can be determined. It should also be observed at this time if the effect of an intervention is comparable in different studies, participants, and settings.

6. Write the Systematic Review

The PRISMA 12 and ENTREQ 13 checklists can be useful resources when writing a systematic review. These uniform reporting tools focus on how to write coherent and comprehensive reviews that facilitate readers and reviewers in evaluating the relative strengths and weaknesses. A systematic literature review has the same structure as an original research article:

TITLE : The systematic review title should indicate the content. The title should reflect the research question, however it should be a statement and not a question. The research question and the title should have similar key words.

STRUCTURED ABSTRACT: The structured abstract recaps the background, methods, results and conclusion in usually 250 words or less.

INTRODUCTION: The introduction summarizes the topic or problem and specifies the practical significance for the systematic review. The first paragraph or two of the paper should capture the attention of the reader. It might be dramatic, statistical, or descriptive, but above all, it should be interesting and very relevant to the research question. The topic or problem is linked with earlier research through previous attempts to solve the problem. Gaps in the literature regarding research and practice should also be noted. The final sentence of the introduction should clearly state the purpose of the systematic review.

METHODS: The methods provide a specification of the study protocol with enough information so that others can reproduce the results. It is important to include information on the:

• Eligibility criteria for studies: Who are the patients or subjects? What are the study characteristics, interventions, and outcomes? Were there language restrictions?
• Literature search: What databases were searched? Which key search terms were used? Which years were searched?
• Study selection: What was the study selection method? Was the title screened first, followed by the abstract, and finally the full text of the article?
• Data extraction: What data and information will be extracted from the articles?
• Data analysis: What are the statistical methods for handling any quantitative data?

RESULTS: The results should also be well-organized. One way to approach the results is to include information on the:

• Search results: What are the numbers of articles identified, excluded, and ultimately eligible?
• Study characteristics: What are the type and number of subjects? What are the methodological features of the studies?
• Study quality score: What is the overall quality of included studies? Does the quality of the included studies affect the outcome of the results?
• Results of the study: What are the overall results and outcomes? Could the literature be divided into themes or categories?

DISCUSSION: The discussion begins with a nonnumeric summary of the results. Next, gaps in the literature as well as limitations of the included articles are discussed with respect to the impact that they have on the reliability of the results. The final paragraph provides conclusions as well as implications for future research and current practice. For example, questions for future research on this topic are revealed, as well as whether or not practice should change as a result of the review.

REFERENCES: A complete bibliographical list of all journal articles, reports, books, and other media referred to in the systematic review should be included at the end of the paper. Referencing software can facilitate the compilation of citations and is useful in terms of ensuring the reference list is accurate and complete.

The following resources may be helpful when writing a systematic review:

CEBM: Centre for Evidence-based Medicine. Dedicated to the practice, teaching and dissemination of high quality evidence based medicine to improve health care Available at: http://www.cebm.net/ .

CITING MEDICINE: The National Library of Medicine Style Guide for Authors, Editors, and Publishers. This resource provides guidance in compiling, revising, formatting, and setting reference standards. Available at http://www.ncbi.nlm.nih.gov/books/NBK7265/ .

EQUATOR NETWORK: Enhancing the QUAlity and Transparency Of health Research. The EQUATOR Network promotes the transparent and accurate reporting of research studies. Available at: http://www.equator-network.org/ .

ICMJE RECOMMENDATIONS: International Committee of Medical Journal Editors Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals. The ICJME recommendations are followed by a large number of journals. Available at: http://www.icmje.org/about-icmje/faqs/icmje-recommendations/ .

PRISMA STATEMENT: Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Authors can utilize the PRISMA Statement checklist to improve the reporting of systematic reviews and meta-analyses. Available at: http://prisma-statement.org .

THE COCHRANE COLLABORATION: A reliable source for making evidence generated through research useful for informing decisions about health. Available at: http://www.cochrane.org/ .

Examples of Systematic Reviews To Link Research and Quality Improvement

Over the past 17 years more than 300 learners, including physicians, nurses, and health administrators have completed a course as part of a Master of Health Administration or a Master of Science in Health Informatics degree at the University of Missouri. An objective of the course is to educate health informatics and health administration professionals about how to utilize a systematic, scientific, and evidence-based approach to literature searching, appraisal, and synthesis. Learners in the course conduct a systematic review of the literature on a health care topic of their choosing that could suggest quality improvement in their organization. Students select topics that make sense in terms of their core educational competencies and are related to their work. The categories of topics include public health, leadership, information management, health information technology, electronic medical records, telehealth, patient/clinician safety, treatment/screening evaluation cost/finance, human resources, planning and marketing, supply chain, education/training, policies and regulations, access, and satisfaction. Some learners have published their systematic literature reviews 14 – 15 . Qualitative comments from the students indicate that the course is well received and the skills learned in the course are applicable to a variety of health care settings.

Undertaking a literature review includes identification of a topic of interest, searching and retrieving the appropriate literature, assessing quality, extracting data and information, analyzing and synthesizing the findings, and writing a report. A structured step-by-step approach facilitates the development of a complete and informed literature review.

Suzanne Austin Boren, PhD, MHA, (above) is Associate Professor and Director of Academic Programs, and David Moxley, MLIS, is Clinical Instructor and Associate Director of Executive Programs. Both are in the Department of Health Management and Informatics at the University of Missouri School of Medicine.

Contact: ude.iruossim.htlaeh@snerob

None reported.

How to Perform a Systematic Literature Review

A Guide for Healthcare Researchers, Practitioners and Students

• © 2020
• Edward Purssell   ORCID: https://orcid.org/0000-0003-3748-0864 0 ,
• Niall McCrae   ORCID: https://orcid.org/0000-0001-9776-7694 1

School of Health Sciences, City, University of London, London, UK

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Florence Nightingale Faculty of Nursing Midwifery & Palliative Care, King’s College London, London, UK

• Presents a logical approach to systematic literature reviewing
• offers a corrective to flawed guidance in existing books
• An accessible but intellectually stimulating guide with illuminating examples and analogies

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Table of contents (11 chapters)

Front matter, introduction.

• Edward Purssell, Niall McCrae

A Brief History of the Systematic Review

The aim and scope of a systematic review: a logical approach, searching the literature, screening search results: a 1-2-3 approach, critical appraisal: assessing the quality of studies, reviewing quantitative studies: meta-analysis and narrative approaches, reviewing qualitative studies and metasynthesis, reviewing qualitative and quantitative studies and mixed-method reviews, meaning and implications: the discussion, making an impact: dissemination of results, back matter.

• Methodology
• Evidence-based practice

About this book

The systematic review is a rigorous method of collating and synthesizing evidence from multiple studies, producing a whole greater than the sum of parts. This textbook is an authoritative and accessible guide to an activity that is often found overwhelming. The authors steer readers on a logical, sequential path through the process, taking account of the different needs of researchers, students and practitioners. Practical guidance is provided on the fundamentals of systematic reviewing and also on advanced techniques such as meta-analysis. Examples are given in each chapter, with a succinct glossary to support the text.  

This up-to-date, accessible textbook will satisfy the needs of students, practitioners and educators in the sphere of healthcare, and contribute to improving the quality of evidence-based practice. The authors will advise some freely available or inexpensive open source/access resources (such as PubMed, R and Zotero) to help students how to perform a systemic review, in particular those with limited resources.

Authors and Affiliations

Edward Purssell

Florence Nightingale Faculty of Nursing Midwifery & Palliative Care, King’s College London, London, UK

Niall McCrae

About the authors

Dr. Niall McCrae teaches mental health nursing and research methods at the Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care at King’s College London. His research interests are dementia, depression, the impact of social media on younger people, and the history of mental health care. Niall has written two previous books: The Moon and Madness (Imprint Academic, 2011) and The Story of Nursing in British Mental Hospitals: Echoes from the Corridors (Routledge, 2016). He is a regular writer for Salisbury Review magazine. 

In partnershipPurssell and McCrae have written several papers on research methodology and literature reviewing for healthcare journals. Both have extensive experience of teaching literature reviewing at all academic levels, and explaining complex concepts in a way that is accessible to all

Bibliographic Information

Book Title : How to Perform a Systematic Literature Review

Book Subtitle : A Guide for Healthcare Researchers, Practitioners and Students

Authors : Edward Purssell, Niall McCrae

DOI : https://doi.org/10.1007/978-3-030-49672-2

Publisher : Springer Cham

eBook Packages : Medicine , Medicine (R0)

Copyright Information : The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2020

Softcover ISBN : 978-3-030-49671-5 Published: 05 August 2020

eBook ISBN : 978-3-030-49672-2 Published: 04 August 2020

Edition Number : 1

Number of Pages : VII, 188

Number of Illustrations : 7 b/w illustrations, 12 illustrations in colour

Topics : Nursing Research , Nursing Education , Research Skills

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How to Do a Systematic Review: A Best Practice Guide for Conducting and Reporting Narrative Reviews, Meta-Analyses, and Meta-Syntheses

Affiliations.

• 1 Behavioural Science Centre, Stirling Management School, University of Stirling, Stirling FK9 4LA, United Kingdom; email: [email protected].
• 2 Department of Psychological and Behavioural Science, London School of Economics and Political Science, London WC2A 2AE, United Kingdom.
• 3 Department of Statistics, Northwestern University, Evanston, Illinois 60208, USA; email: [email protected].
• PMID: 30089228
• DOI: 10.1146/annurev-psych-010418-102803

Systematic reviews are characterized by a methodical and replicable methodology and presentation. They involve a comprehensive search to locate all relevant published and unpublished work on a subject; a systematic integration of search results; and a critique of the extent, nature, and quality of evidence in relation to a particular research question. The best reviews synthesize studies to draw broad theoretical conclusions about what a literature means, linking theory to evidence and evidence to theory. This guide describes how to plan, conduct, organize, and present a systematic review of quantitative (meta-analysis) or qualitative (narrative review, meta-synthesis) information. We outline core standards and principles and describe commonly encountered problems. Although this guide targets psychological scientists, its high level of abstraction makes it potentially relevant to any subject area or discipline. We argue that systematic reviews are a key methodology for clarifying whether and how research findings replicate and for explaining possible inconsistencies, and we call for researchers to conduct systematic reviews to help elucidate whether there is a replication crisis.

Keywords: evidence; guide; meta-analysis; meta-synthesis; narrative; systematic review; theory.

• Guidelines as Topic
• Meta-Analysis as Topic*
• Publication Bias
• Review Literature as Topic
• Systematic Reviews as Topic*

Systematic Review

What is a systematic review, types of systematic reviews, steps in a systematic review.

• Developing a search strategy
• Search techniques
• Systematically search databases
• Appraisal & synthesis
• Reporting findings
• Systematic review tools

Research Services Team

For further help email us at: [email protected]

A systematic review is commonly characterised by:

• A well-defined research question
• Transparent search terms and database selection
• Exclusion/inclusion criteria with evaluation of search findings
• A research project structure with elements such as Introduction, Method, Result, Discussion

A systematic review is considered secondary research because it uses research by others and does not involve data collection for a new research project.

Video: Conducting a systematic literature review   (3.17 mins). A quick overview and comparison with traditional literature reviews.

How is it different from a traditional literature review?

The purpose of systematic review is different from that of a traditional literature review.

A systematic review further

• involves a clearly articulated search process and selection criteria of the literature which is closely examined before being included in the review.
• uses a search and selection procedure that is transparent and can be replicated. 

In a traditional literature review, the researcher

• selects and examines studies related to the research topic.
• does not have to make visible the search and selection process and criteria.

See more detailed comparison for both types of reviews in this PDF:

• Comparison table of traditional and systematic reviews

There are four common types of reviews using systematic methods:

• Systematic literature reviews
• Rapid reviews
• Scoping reviews
• Integrative reviews

For a more detailed comparison, see this PDF:

• Comparison of the common types of reviews

A common feature of these reviews is the goal of reducing bias in the search and selection of studies.

This bias mainly refers to:

• Availability of resources
• Researcher’s degree of objectivity
• Degree of similarity in type and content of research

A common strategy for reducing bias:

• Extended time to perform a thorough search in published and ‘yet to be published’ articles
• Two or more reviewers following transparent processes of conducting searches and making selections
• Homogeneity of selected research articles

Right review

Right review is a tool to assist users selecting a review type from the 41 quantitative or qualitative knowledge synthesis methods.

References and Furtherreading 

Centre for Evidence Synthesis in Health. (2018, January 4). The steps of a systematic review [Video]. YouTube.  https://www.youtube.com/watch?v=-FQSsnaAtOU

Librarian Carrie Price. (2021, May 18). Systematic vs scoping review: What’s the difference [Video]. YouTube. https://www.youtube.com/watch?v=YVckIl8_ZCg

Munn, Z., Peters, M. D. J., Stern, C., Tufanaru, C., McArthur, A., & Aromataris, E. (2018). Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach.  BMC Medical Research Methodology , 18 , Article 143.  https://doi.org/10.1186/s12874-018-0611-x

Munn, Z., Stern, C., Aromataris, E., Lockwood, C., & Jordan, Z. (2018). What kind of systematic review should I conduct? A proposed typology and guidance for systematic reviewers in the medical and health sciences.  BMC Medical Research Methodology ,  18, Article 5.  https://doi.org/10.1186/s12874-017-0468-4

Peters, M. D. J., Godfrey, C., McInerney, P., Munn, Z., Tricco, A. C., Khalil, H. (2020). Scoping reviews. In E. Aromataris, & Z. Munn (Eds.),  JBI manual for evidence synthesis.  Joanna Briggs Institute.  https://doi.org/10.46658/JBIMES-20-12

Peters, M. D. J., Marnie, C., Tricco, A. C., Pollock, D., Munn, Z., Alexander, L., McInerney, P., Godfrey, C. M., & Khalil, H. (2020). Updated methodological guidance for the conduct of scoping reviews.  JBI Evidence Synthesis ,  18 (10), 2119– 2126.  https://doi.org/10.11124/JBIES-20-00167

Pringle, J., Mills, K., McAteer, J., Jepson, R., Hogg, E., Anand, N., & Blakemore, S. J. (2016). A systematic review of adolescent physiological development and its relationship with health-related behaviour: A protocol. Systematic Reviews, 5 , Article 3. https://doi.org/10.1186/s13643-015-0173-5

Temple University Library (2021, June 11).  Systematic reviews & other review types . Retrieved July 8, 2021, from  https://guides.temple.edu/c.php?g=78618&p=3879604

Tricco, A. C., Lillie, E., Zarin, W., O'Brien, K., Colquhoun, H., Kastner, M., Levac, D., Ng, C., Sharpe, J. P., Wilson, K., Kenny, M., Warren, R., Wilson, C., Stelfox, H. T., & Straus, S. E. (2016). A scoping review on the conduct and reporting of scoping reviews.  BMC Medical Research Methodology ,  16 (1), 15.  https://doi.org/10.1186/s12874-016-0116-4

Click on a box below to go to information on that topic.

Further reading 

Bettany-Saltikov, J. (2016). How to do a systematic literature review in nursing: A step-by-step guide (2nd ed.). Open University Press.

Cranwell, M. (2021). A mixed-methods systematic review of transitions for caregivers of people living with dementia . SAGE. 

Muka, T., Glisic, M., Milic, J., Verhoog, S., Bohlius, J. Bramer, W., Chowdhury, R., & Franco, O. H .  (2020). A 24-step guide on how to design, conduct, and successfully publish a systematic review and meta-analysis in medical research.  European Journal of Epidemiology,   35 ,   49–60.  https://doi,org/10.1007/s10654-019-00576-5

Gough, D., Oliver, S., & Thomas, J. (Eds.). (2017). An introduction to systematic reviews  (2nd ed.). SAGE. 

Gough, D., Oliver, S., & Thomas, J. (Eds.). (2018). Systematic reviews and research . SAGE. 

Biondi-Zoccai, G. (Ed.). (2016). Umbrella reviews: Evidence synthesis with overviews of reviews and meta-epidemiologic studies . Springer. https://doi.org/10.1007/978-3-319-25655-9  

Holly, C., Salmond, S., & Saimbert, M. (2021). Comprehensive Systematic Review for Advanced Practice Nursing (3rd ed.). Springer. 

Higgins, J. P. T., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M. J., & Welch, V. A. (Eds). (2021). Cochrane Handbook for Systematic Reviews of Interventions version 6.2. Cochrane. https://training.cochrane.org/handbook . 

Petticrew, M., & Roberts, H. (2006). Systematic reviews in the social sciences: A practical guide . John Wiley & Sons. 

Tawfik, G. M., Dila, K. A. S., Mohamed, M. Y. F., Tam, D. N. H., Kien, N. D., Ahmed, A. M., & Huy, N. T. (2019). A step by step guide for conducting a systematic review and meta-analysis with simulation data. Tropical Medicine Health, 47 , Article 46. https://doi.org/10.1186/s41182-019-0165-6

Tod, D. (2019). Conducting systematic reviews in sport, exercise, and physical activity . Palgrave Macmillan. 

Toronto, C. E., & Remington, R. (Eds.). (2020). A step-by-step guide to conducting an integrative review . Springer. https://doi.org/10.1007/978-3-030-37504-1

 Zawacki-Richter, O., Kerres, M., Bedenlier, S., Bond, M., & Buntins, K. (Eds.). (2020). Systematic Reviews in Educational Research: Methodology, Perspectives and Application . Springer. https://doi.org/10.1007/978-3-658-27602-7

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• Last Updated: Mar 13, 2024 9:39 AM
• URL: https://aut.ac.nz.libguides.com/systematic_reviews

How to do a Systematic Literature Review in Nursing: A step-by-step guide (2nd Edition)

• School of Health & Life Sciences

Research output : Book/Report › Book

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• Literature Review Arts & Humanities 100%
• Nursing Arts & Humanities 89%
• Workbook Arts & Humanities 44%
• Pitfalls Arts & Humanities 29%
• Clinical Practice Arts & Humanities 29%
• Companionship Arts & Humanities 27%
• Healthcare Arts & Humanities 19%

T1 - How to do a Systematic Literature Review in Nursing: A step-by-step guide (2nd Edition)

AU - Bettany-Saltikov, Josette

AU - McSherry, Robert

PY - 2016/4

Y1 - 2016/4

N2 - This is a step-by-step guide to doing a literature review in nursing, or related healthcare professions, that takes you through every step of the process from start to finish. From writing your review question to writing up your review, this practical book is the perfect workbook companion if you are doing your first literature review for study or clinical practice improvement. The book features sample review case studies to help identify good practice as well as the pitfalls to avoid, and the practical explanations will be invaluable at every stage.

AB - This is a step-by-step guide to doing a literature review in nursing, or related healthcare professions, that takes you through every step of the process from start to finish. From writing your review question to writing up your review, this practical book is the perfect workbook companion if you are doing your first literature review for study or clinical practice improvement. The book features sample review case studies to help identify good practice as well as the pitfalls to avoid, and the practical explanations will be invaluable at every stage.

SN - 9780335263806

BT - How to do a Systematic Literature Review in Nursing: A step-by-step guide (2nd Edition)

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How to do a Systematic Literature Review in Nursing. A Step-by-Step Guide

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Fazekas T , Shim SR , Basile G, et al. Magnetic Resonance Imaging in Prostate Cancer Screening : A Systematic Review and Meta-Analysis . JAMA Oncol. Published online April 05, 2024. doi:10.1001/jamaoncol.2024.0734

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Magnetic Resonance Imaging in Prostate Cancer Screening : A Systematic Review and Meta-Analysis

• 1 Comprehensive Cancer Center, Department of Urology, Medical University of Vienna, Vienna, Austria
• 2 Department of Urology, Semmelweis University, Budapest, Hungary
• 3 Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
• 4 Department of Biomedical Informatics, College of Medicine, Konyang University, Daejeon, Republic of Korea
• 5 Unit of Urology, Urological Research Institute, Division of Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
• 6 Department of Urology, Assistance Publique des Hôpitaux de Marseille, North Academic Hospital, Marseille, France
• 7 Institute of Mathematics, Department of Stochastics, Budapest University of Technology and Economics, Budapest, Hungary
• 8 Department of Urology, Jagiellonian University Medical College, Krakow, Poland
• 9 Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
• 10 The National Center for Diabetes, Endocrinology and Genetics, The University of Jordan, Amman, Jordan
• 11 Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France
• 12 Division of Surgery and Interventional Science, University College London, London, England
• 13 Department of Urology, Hospital Universitario La Paz, Madrid, Spain
• 14 Department of Urology, University of Duisburg-Essen and German Cancer Consortium–University Hospital Essen, Essen, Germany
• 15 Department of Radiology and Nuclear Medicine, Erasmus MC Cancer Institute, University Medical Centre, Rotterdam, the Netherlands
• 16 Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
• 17 Department of Urology, St Antonius Hospital, Utrecht, the Netherlands
• 18 Department of Urology, Erasmus MC, Rotterdam, the Netherlands
• 19 Department of Urology, Yale School of Medicine, New Haven, Connecticut
• 20 Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
• 21 Department of Urology, University of Texas Southwestern Medical Center, Dallas
• 22 Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
• 23 Department of Urology, Weill Cornell Medical College, New York, New York
• 24 Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
• 25 Department of Urology, Medical University of Silesia, Zabrze, Poland

Question   Do prostate cancer screening pathways that incorporate magnetic resonance imaging (MRI) and targeted biopsies outperform strategies that rely solely on prostate-specific antigen testing and systematic biopsy?

Findings   In this systematic review and meta-analysis of 80 114 screened men from 12 studies, MRI-based screening was found to be associated with a reduced number of unnecessary prostate biopsies and detection of clinically insignificant prostate cancer while maintaining the detection of clinically significant prostate cancer compared with prostate-specific antigen–only strategies.

Meaning   The findings of this meta-analysis support the integration of prostate MRI in prostate cancer screening to improve the balance of patient harms and benefits.

Importance   Prostate magnetic resonance imaging (MRI) is increasingly integrated within the prostate cancer (PCa) early detection pathway.

Objective   To systematically evaluate the existing evidence regarding screening pathways incorporating MRI with targeted biopsy and assess their diagnostic value compared with prostate-specific antigen (PSA)–based screening with systematic biopsy strategies.

Data Sources   PubMed/MEDLINE, Embase, Cochrane/Central, Scopus, and Web of Science (through May 2023).

Study Selection   Randomized clinical trials and prospective cohort studies were eligible if they reported data on the diagnostic utility of prostate MRI in the setting of PCa screening.

Data Extraction   Number of screened individuals, biopsy indications, biopsies performed, clinically significant PCa (csPCa) defined as International Society of Urological Pathology (ISUP) grade 2 or higher, and insignificant (ISUP1) PCas detected were extracted.

Main Outcomes and Measures   The primary outcome was csPCa detection rate. Secondary outcomes included clinical insignificant PCa detection rate, biopsy indication rates, and the positive predictive value for the detection of csPCa.

Data Synthesis   The generalized mixed-effect approach with pooled odds ratios (ORs) and random-effect models was used to compare the MRI-based and PSA-only screening strategies. Separate analyses were performed based on the timing of MRI (primary/sequential after a PSA test) and cutoff (Prostate Imaging Reporting and Data System [PI-RADS] score ≥3 or ≥4) for biopsy indication.

Results   Data were synthesized from 80 114 men from 12 studies. Compared with standard PSA-based screening, the MRI pathway (sequential screening, PI-RADS score ≥3 cutoff for biopsy) was associated with higher odds of csPCa when tests results were positive (OR, 4.15; 95% CI, 2.93-5.88; P  ≤ .001), decreased odds of biopsies (OR, 0.28; 95% CI, 0.22-0.36; P  ≤ .001), and insignificant cancers detected (OR, 0.34; 95% CI, 0.23-0.49; P  = .002) without significant differences in the detection of csPCa (OR, 1.02; 95% CI, 0.75-1.37; P  = .86). Implementing a PI-RADS score of 4 or greater threshold for biopsy selection was associated with a further reduction in the odds of detecting insignificant PCa (OR, 0.23; 95% CI, 0.05-0.97; P  = .048) and biopsies performed (OR, 0.19; 95% CI, 0.09-0.38; P  = .01) without differences in csPCa detection (OR, 0.85; 95% CI, 0.49-1.45; P  = .22).

Conclusion and relevance   The results of this systematic review and meta-analysis suggest that integrating MRI in PCa screening pathways is associated with a reduced number of unnecessary biopsies and overdiagnosis of insignificant PCa while maintaining csPCa detection as compared with PSA-only screening.

Prostate-specific antigen (PSA)–based prostate cancer (PCa) screening has been shown to reduce PCa-specific mortality, but it is also associated with unnecessary biopsies, overdiagnosis, overtreatment, and an unclear effect on overall survival. 1 , 2 To balance these risks and benefits, clinical practice guidelines recommend shared decision-making strategies to identify informed candidates who are most likely to benefit from PCa early detection. 3 , 4 However, this opportunistic approach has been associated with widespread but untargeted testing accompanied by disparities in health care access and literacy. 3 - 5 Moreover, the inherent limitations of PSA-based PCa screening, including excess biopsies and overtreatment of low-grade disease, have not been addressed. 5 , 6

Prebiopsy prostate magnetic resonance imaging (MRI) followed by targeted biopsies has been widely integrated in the diagnostic pathway for PCa, as it is associated with improved detection of clinically significant PCa and reduced numbers of avoidable biopsies and insignificant cancers in the clinical setting. 3 , 7 , 8 As a result, clinical practice guidelines have recommended prebiopsy MRI; however, to our knowledge, there is no consensus about the role of MRI as an integrated PCa screening tool. 3 , 4 Consequently, several ongoing clinical trials are investigating the value of incorporating prebiopsy MRI with targeted biopsy into population-based PCa screening protocols to overcome the limitations of conventional PSA-based screening.

In the setting of a large body of literature addressing the diagnostic role of prostate MRI and its growing global use, there is a need to synthesize evidence to inform clinical practice and help devise a screening strategy that incorporates MRI information. To address this unmet need, in this systematic review and meta-analysis, we summarized the currently available literature on the performance of PCa population-based screening strategies that incorporate MRI and compared them with PSA only–based screening approaches. We hypothesized that PSA-MRI–based PCa screening strategies would outperform PSA only–based screening in terms of clinically relevant end points.

This systematic review and meta-analysis was reported according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses ( PRISMA ) 2020 guideline (eTable 1 in Supplement 1 ) and the Cochrane Handbook. 9 , 10 The study protocol was registered on PROSPERO.

To evaluate the performance of MRI-based screening strategies, we used the population, intervention, control, and outcomes framework. 11 We included studies of men in the general population or those with elevated genetic risk for PCa who were screened for PCa (population) who underwent MRI examination as part of the screening (intervention) and were compared with men screened for PCa using PSA alone (comparison). Studies were selected if they reported data in screening-like populations, while those addressing diagnostic test accuracy or those that enrolled preselected men to undergo biopsy (men with lower urinary tract symptoms, elevated PSA levels, or suspect digital rectal examination results) were excluded. The primary end point was the cancer detection rate (CDR) of clinically significant PCa, defined as an International Society of Urological Pathology (ISUP) grade of 2 or higher (outcome). Secondary end points included the CDR of insignificant PCa (defined as ISUP grade 1), positive predictive values (PPVs) for detecting significant and insignificant PCas, MRI and biopsy indication, biopsy adherence, and complication rates. Moreover, we calculated CDRs using alternative definitions of significant (ISUP ≥3) and insignificant (ISUP 1-2) PCa. This meta-analysis was restricted to prospective observational or randomized studies.

The MEDLINE (via PubMed), Embase, Cochrane/Central, Scopus, and Web of Science databases were queried on May 5, 2023, to identify all available studies containing information on MRI-based screening strategies. After selection by 2 independent review authors (T.F. and G.B.), the following data were extracted from the eligible studies: general information; study population characteristics; details of the intervention and comparator, including screening algorithm (MRI in first-line/sequential screening), sequence (biparametric/multiparametric), and type (1.5T/3T) of MRI; Prostate Imaging Reporting and Data System (PI-RADS) cutoff for the indication of biopsy (PI-RADS ≥3 or ≥4); type of biopsy approach (targeted + systematic/targeted only, cognitive/image-fusion); PSA cutoff; additional novel biomarkers in the screening pathway; and the outcomes of interest described previously. 12 In cases in which studies did not provide information on the specified outcomes, 2 authors (T.F. and G.B.) independently calculated them using the data provided within the studies. Any disagreements on study selection and data extraction were resolved through consensus with a third author (P.R.). Sensitivity, specificity, and negative predictive value could not be evaluated because prostate biopsies were not performed in cases of negative screening test results. To address inconsistencies or overlapping data among studies, we made adjustments to the study samples (eTable 2 in Supplement 1 ). More detailed descriptions of the inclusion criteria, search strategy, selection, and data extraction process are presented in eAppendix 1 and eTables 2 to 3 in Supplement 1 .

Quantitative data synthesis was conducted with the R statistical software (version 4.1; R Core Team) and adhered to the methods recommended by the working group of the Cochrane Collaboration. 10 Based on the likely heterogeneity of the studies included, we used random-effect models for our calculations. 13 , 14 To assess and compare CDR, PPV, MRI, biopsy indication rates, and adherence to biopsy of the different screening pathways, we calculated pooled event rates and odds ratios (ORs) with 95% CIs using the generalized mixed-effect approach. 15 To assess the optimal timing of MRI in the screening pathway, we conducted separate analyses based on different PI-RADS cutoffs for indicating biopsy (≥3, ≥4) and MRI timing (primary/sequential). We used forest plots to visualize event rates and effect measures. To evaluate the moderator effect of different factors, type of MRI sequence, biopsy technique, and study design, we performed subgroup analyses. Heterogeneity was assessed by calculating the I 2 measure and its CI. For all statistical analyses, P  ≤ .05 was considered significant. Publication bias could not be assessed due to the low number of articles for 1 outcome. 16 Full details of the statistical analysis are described in eAppendix 1 in Supplement 1 . No ethical approval was required for this systematic review and meta-analysis as already published secondary data were used.

For randomized and nonrandomized studies, the risk of bias (RoB) was evaluated according to the Cochrane Collaboration’s RoB assessment (RoB2) and the Risk of Bias in Nonrandomized Studies of Interventions tools independently by 2 reviewers (T.F. and G.B.). 17 , 18 Disagreements were resolved via consensus with a third author (P.R.).

The search key identified 2037 studies, of which 1464 were screened after removing duplicates. Finally, from the 28 full-text selected studies, 12 and 8 were eligible for qualitative and quantitative evidence synthesis, respectively ( Figure 1 ). A detailed explanation for the exclusion of the studies can be found in eAppendix 2 in Supplement 1 . Table 1 19 - 30 shows the baseline characteristics of the included studies. Overall, we assessed 80 114 screened individuals from 12 studies. We identified 4 population-based randomized clinical trials, 2 prospective cohort studies, and 3 prospective pilot studies. 19 - 25 , 28 - 30 Moreover, we included 2 studies that reported on the efficacy of MRI in a prescreened population. 26 , 27 We identified 4 studies that reported data on the use of novel molecular biomarkers and MRI in PCa screening. 23 , 28 - 30 Most publications included data on the use of MRI as a sequential screening tool (after PSA prescreening); however, 3 studies were identified reporting on up-front MRI. 19 , 24 , 25 Five studies used biparametric MRI (bpMRI), and 8 included multiparametric MRI (mpMRI) ( Table 1 ). As for the method of biopsy, 7 studies used MRI targeted only, while 6 studies used additional systematic sampling ( Table 1 ). For further details on the studies and interventions, please refer to eTables 4 and 5 in Supplement 1 .

We synthesized data from 57 081 men that were derived from 6 articles that applied MRI in a PSA-prescreened population (as part of sequential screening), with a PI-RADS score of 3 or higher as a cutoff as the biopsy indication. 19 - 22 , 26 , 27 A detailed overview of CDRs, PPVs, biopsy indication, and adherence rates can be found in Table 2 and eFigures 1 to 4 in Supplement 1 . The number of men needed to screen to detect 1 significant PCa was 59 and 63 for PSA only and MRI-based strategies, respectively. Although we found no difference between the MRI-only and PSA-only screening methods in terms of clinically significant CDR (OR, 1.02; 95% CI, 0.75-1.37; P  = .86) (eFigure 1 in Supplement 1 ), the MRI pathway was associated with lower odds of insignificant PCa detection (OR, 0.34; 95% CI, 0.23-0.49; P  = .002) ( Figure 2 ). 19 , 20 , 22 , 26 , 27 These trends in CDR remained similar when alternative definitions were applied for significant (ISUP ≥3: OR, 0.91; 95% CI, 0.54-1.52; P  = .40) and insignificant PCas (ISUP 1-2: OR, 0.54; 95% CI, 0.23-1.29; P  = .09) (eFigure 5 in Supplement 1 ). Furthermore, screening strategies that incorporated MRI had a higher PPV for detecting significant PCa (OR, 4.15; 95% CI, 2.93-5.88; P  = .001) and a lower biopsy rate (OR, 0.28; 95% CI, 0.22-0.36; P  < .001) than PSA-only-based ones ( Figure 2 ; eFigures 2 and 3 in Supplement 1 ). 19 , 20 , 22 , 26 , 27 The pooled rate of MRI was 8.5% (95% CI, 2.6%-24.8%; I 2  = 100%) among the screened individuals, and biopsy adherence was higher when MRI was used (OR, 4.61; 95% CI, 2.39-8.89; P  = .01) (eFigure 4 in Supplement 1 ). 19 - 22 , 26 , 27 To identify the high rate of heterogeneity among the studies and assess the role of possible confounders, we stratified studies based on the type of MRI sequence, biopsy method, and study design (eFigures 6 and 7 in Supplement 1 ). We observed differences in terms of PPV, but not in CDR and biopsy rates. Compared with mpMRI, the use of bpMRI was associated with a higher PPV for significant PCa (61.1% [95% CI, 26.5%-87.3%] vs 34.8% [95% CI, 25.2%-45.7%]; P  < .001) and a lower PPV for insignificant PCa (11.5% [95% CI, 1.3%-55.1%] vs 19.5% [95% CI, 12.3%-29.6%]; P  = .01), respectively, without heterogeneity across the subgroups (eFigures 7A and 7E in Supplement 1 ).Targeted + systematic (vs targeted) and image fusion (vs cognitive) biopsies had a lower PPV for insignificant cancers (eFigures 7F and 7G in Supplement 1 ).

Among 19 501 patients who underwent prostate MRI that used a PI-RADS cutoff of 4 or higher as a biopsy indication, we observed even lower odds of insignificant PCa detection (OR, 0.23; 95% CI, 0.05-0.97; P  = .048) and biopsy (OR, 0.19; 95% CI, 0.09-0.38; P  = .01) with a higher PPV (OR, 7.01; 95% CI, 1.76-27.98; P  = .03) and similar CDR (OR, 0.85; 95% CI, 0.49-1.45; P  = .23) for significant disease compared with standard PSA-only screening ( Figure 3 ; eFigures 8-10 in Supplement 1 ). 19 , 20 , 27

To evaluate the performance of MRI (PI-RADS ≥4) as a primary screening tool, we synthesized data from 3 articles that involved 983 men. 19 , 24 , 25 Clinically significant and insignificant CDRs were 6% (95% CI, 0.6%-39.4%; I 2 : 92%) and 1.2% (95% CI, 0.2%-7.3%; I 2 : 55%), respectively (eFigures 11A and 11B in Supplement 1 ). The PPV of up-front MRI to detect significant PCa was 41.9% (95% CI, 16.1%-73%; I 2 : 57%) (eFigure 11C in Supplement 1 ). Due to the limited availability of data, comparison of MRI-based screening with PSA-based approaches was only feasible in terms of biopsy selection, which revealed no significant difference between the 2 strategies (OR, 0.81; 95% CI, 0.23-2.87; P  = .50) (eFigure 12C in Supplement 1 ). 19 , 24 , 25

We identified 4 articles that reported on the combination of MRI and novel biomarkers; however, given the heterogeneity between populations and interventions within studies, we did not perform a quantitative data synthesis. 23 , 28 - 30 In this subset, the use of novel biomarkers was associated with fewer insignificant PCas while maintaining significant disease detection. 23 , 28 Moreover, MRI has been shown to be an effective screening tool in patients with a genetic predisposition for PCa. 30

The RoB 2 and Risk of Bias in Nonrandomized Studies of Interventions tools identified a low overall RoB in most of the included studies for the CDR, PPV, MRI, and biopsy rates and adherence to biopsy indication outcomes (eFigures 13 and 14 in Supplement 1 ). Among randomized clinical trials, the intervention in the PROBASE trial was found to be biased, as MRI examination was not part of the screening protocol; however, MRI data were available in 79% of participants, and 114 of 120 men (95%) underwent MRI/ultrasonography fusion-targeted and systematic biopsy. 21 Despite some prospective cohort studies that showed a moderate risk in categories that was mainly based on the population of the study, most of these articles displayed a low overall RoB.

To our knowledge, this systematic review and meta-analysis was the first to assess the performance of MRI in the setting of PCa screening. There were several notable and clinically relevant findings from this study. First, these analyses suggested that MRI as part of sequential screening performs similarly to conventional PSA-based strategies in detecting clinically significant PCa while reducing the number of detected insignificant cancers. Second, prebiopsy MRI was associated with a substantially reduced number of unnecessary prostate biopsies performed and enhanced the PPV for significant PCa detection compared with PSA-only screening with standard biopsies. Moreover, modifying the threshold of offering prostate biopsy to a PI-RADS score of 4 or higher and the use of bpMRI may further be associated with a reduced rate of unnecessary biopsies while not meaningfully compromising the detection of significant PCa. Finally, the results of this study suggest that MRI as a first-line screening tool does not seem to exhibit the aforementioned benefits in reducing biopsy rates and the detection of insignificant PCa.

Our findings support and potentially strengthen the cumulative evidence suggesting that the use of MRI following initial PSA prescreen is associated with decreased detection of insignificant PCa compared with PSA-only approaches. Thus, MRI may be a useful tool to mitigate the limitations of PSA-based screening, including overdiagnosis of indolent PCa, which can be associated with overtreatment with avoidable complications associated with any therapy. 31 , 32 However, the 2 screening strategies were similar in terms of CDR for clinically significant disease. Based on our analysis, the number needed to screen to detect 1 significant PCa was 59 and 63 for PSA-only and MRI-based strategies, respectively.

Moreover, use of MRI-based screening strategies was associated with higher PPV for detecting clinically significant PCa and a reduced number of biopsy indications. Based on our findings, the number of biopsies needed to detect 1 significant prostate cancer was 2 and 6 with MRI-based and PSA-only screening, respectively. These findings are notable given the risks of bleeding, infection, discomfort, and expense associated with prostate biopsy, as well as the psychological burden of screening-triggered workup. 33 , 34 Moreover, avoiding biopsy and following up with patients with negative MRI results were shown to be a safe approach in screening. 35 , 36 According to the data presented in this article, patients are more willing to undergo biopsy when the indication is underlined with MRI results, which is an important factor in achieving better outcomes and a more equal distribution of health care resources. 5 , 37 - 39 In modeling studies, MRI-based PCa screening is associated with an improvement in the benefit-harm profile, quality of life, cost-effectiveness, and environmental effect of screening for PCa compared with standard PSA-based screening. 40 - 44 Accordingly, our results synthesizing high-quality prospective data suggested that MRI is effective at identifying individuals who are most likely to require further evaluation and biopsy, potentially reducing the burden on health care resources and sparing patients from having to undergo unnecessary invasive procedures.

This study aggregates performance characteristics of MRI-based screening across PI-RADS cutoffs for biopsy selection, different sequences (multiparametric or biparametric), biopsy methods (targeted only or targeted + systematic), and fusion types (cognitive or image fusion). Our analysis suggests that implementing a PI-RADS score of 4 or higher as a cutoff is further associated with a reduced number of insignificant cancers detected and biopsies performed. Additionally, the choice of MRI sequence, whether biparametric or multiparametric, is an important aspect of screening, as shorter bpMRI protocols are faster, more cost-effective, and are associated with reduced exposure to contrast material, making them valuable in the screening process. 45 , 46 However, bpMRI interpretation may be more challenging, requiring a higher level of expertise. 47 We found that bpMRI is associated with a higher PPV for detecting significant PCa, which may be attributable to preferentially identifying larger, more conspicuous lesions in the absence of contrast. 45 , 48 Lastly, we examined the role of biopsy approach on MRI-based screening outcomes. These results revealed no significant differences in terms of CDR and PPV for significant disease between the targeted-only and targeted + systematic biopsy techniques, as well as between image fusion and cognitive biopsy methods. However, the targeted + systematic and image-fusion biopsies demonstrated a lower PPV for detecting clinically insignificant prostate cancer. These findings suggest that a screening pathway incorporating bpMRI following PSA prescreening coupled with a PI-RADS score of 4 or higher as a cutoff for biopsy indication may be a promising strategy for increasingly accessible and cost-effective screening. However, several questions remain to be addressed in future investigations, including whether to use targeted-only biopsy, the optimal method for fusion biopsy, a comprehensive analysis of screening costs, and an examination of long-term survival outcomes. Furthermore, differences in oncologic risk profiles have been observed between PCa cases diagnosed via MRI-based targeted biopsy and those identified through standard biopsy methods. 49 These findings underscore the need for further research to elucidate the behavior of PCas identified with MRI and targeted biopsy and their implications for treatment strategies.

Our study also highlights the importance of considering the timing and type of MRI and biopsy in the screening process. While MRI following PSA prescreening (sequential pathway) demonstrated numerous advantages compared with PSA-only strategies, up-front MRI as a primary tool did not appear to exhibit the aforementioned benefits in terms of biopsy rates and insignificant PCa detection; however, it was associated with CDR for significant PCa. Although these results are limited by the lack of data for formal statistical comparison, this suggests that while MRI is valuable for refining the selection of patients for biopsy, its use as a primary screening tool needs to be further assessed in the future. Interestingly, among men younger than 55 who harbor breast cancer gene ( BRCA ) germline alterations, up-front MRI has been demonstrated to have the highest clinical benefit, highlighting its diagnostic value for patients with a genetic predisposition for PCa. 30

This study had several limitations. These included a relatively low number of articles that could be included. Subgroup evaluation, heterogeneity, and publication bias assessment were limited. As no biopsy was performed in case of a negative MRI result, sensitivity, specificity, and negative predictive values could not be assessed. Most of the studies assessed a Scandinavian population, limiting the generalizability of our findings. Safety and long-term survival data could not be synthesized, constraining the full-scale interpretation of our results. Finally, the optimal intensity and interval of MRI-based screening rounds have yet to be established, which require consideration of trade-offs regarding frequency of procedures, cancer detection, and associated costs.

The results of this systematic review and meta-analysis suggest that prostate MRI with targeted biopsies is an effective strategy for the early detection of prostate cancer. We found that MRI mitigates pitfalls of standard PSA-based strategies, as it can be associated with fewer unnecessary biopsies and helps to avoid the detection of insignificant cancers while not comprising significant disease detection. Our results highlight the need to reassess our approach to population-based screening; however, the optimal setup of MRI and biopsy scheme in the screening process requires further evaluation.

Accepted for Publication: January 22, 2024.

Published Online: April 5, 2024. doi:10.1001/jamaoncol.2024.0734

Corresponding Author: Shahrokh F. Shariat, MD, DDr(hc), Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria ( [email protected] ).

Author Contributions: Drs Fazekas and Rajwa had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Fazekas, Przydacz, Ploussard, Rivas, Gandaglia, Szarvas, Van Den Bergh, Nyirády, Shariat, Rajwa.

Acquisition, analysis, or interpretation of data: Fazekas, Shim, Basile, Baboudjian, Kói, Abufaraj, Kasivisvanathan, Schoots, Leapman, Shariat, Rajwa.

Drafting of the manuscript: Fazekas, Basile, Kói, Gandaglia, Szarvas, Leapman, Nyirády, Rajwa.

Critical review of the manuscript for important intellectual content: Shim, Basile, Baboudjian, Przydacz, Abufaraj, Ploussard, Kasivisvanathan, Rivas, Schoots, Van Den Bergh, Leapman, Shariat, Rajwa.

Statistical analysis: Fazekas, Shim, Baboudjian, Kói.

Obtained funding: Shariat.

Administrative, technical, or material support: Shim, Przydacz, Abufaraj, Ploussard, Leapman, Shariat, Rajwa.

Supervision: Ploussard, Kasivisvanathan, Rivas, Szarvas, Van Den Bergh, Leapman, Nyirády, Shariat, Rajwa.

Other—validation, software, data curation, methodology: Shim.

Conflict of Interest Disclosures: Dr Fazekas reported grants from the Ministry for Innovation and Technology New National Excellence Program and the European Association of Urology EUSP Scholarship during the conduct of the study. Dr Kasivisvanathan reported personal fees from the European Association of Urology and salary support from Prostate Cancer UK and the John Black Charitable Foundation outside the submitted work. Dr Kói received grant support from the National Research, Development and Innovation Office. No other disclosures were reported.

Funding/Support: This work was supported by the EUSP Scholarship of the European Association of Urology (Dr Fazekas; S-2023-0006) and grants from the New National Excellence Program of the Ministry for Innovation and Technology from the National Research Development, and Innovation Fund (Dr Fazekas; ÚNKP-22-3-1-SE-19) and the Hungarian National Eötvös Grant of the Hungarian state (Dr Fazekas).

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: This article was presented at the European Association of Urology Congress; April 5, 2024; Paris, France.

Data Sharing Statement: See Supplement 2 .

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