Not all PI-RADS 3 lesions are the same: Higher rate of clinically significant prostate cancer among Black men on targeted biopsy in a diverse cohort

Background and Objective Radiogenomic studies suggest phenotypic differences in prostate cancer (PCa) appearance on MRI across racial groups. Counseling for PI-RADS 3 lesions is particularly challenging due to low positive predictive value and limited multi-ethnic data. We evaluated the association between PI-RADS score and PCa detection on MRI-targeted biopsy across a diverse patient population. Methods We conducted a retrospective study of patients who underwent MRI-targeted fusion biopsy for PI-RADS 3 to 5 lesions between 2016 and 2024. Demographic and pathologic data were collected. Mixed-effects logistic regression assessed associations between race and PCa and csPCa, adjusting for clinical/radiographic features, stratified by PI-RADS score. Results 646 patients with 1,146 lesions were analyzed (mean age 63.2 ± 7.6). The cohort was 48.1% Non-Hispanic Black (NHB), 32.5% Hispanic, and 19.3% Non-Hispanic White (NHW). PCa detection rates were 45.0% in NHB, 36.0% in Hispanic, and 35.8% in NHW. NHB had increased odds of overall and csPCa detection compared to NHW (Odds Ratio [OR] = 2.00; 95% Confidence Interval [95% CI] 0.96–4.18; P = 0.06, OR = 1.78, 95% CI 0.85–3.71; P = 0.12). On biopsy of PI-RADS 3 lesions, NHB men demonstrated nearly fivefold higher odds of csPCa detection compared to NHW and Hispanic cohorts (OR = 4.86; 95% CI 1.26–18.77; P = 0.02). No significant differences were observed between Hispanic and NHW men. Conclusions NHB had significantly higher odds of csPCa detection on targeted biopsy of PI-RADS 3 lesions. These findings support emerging data that phenotypic appearance of prostate cancer on MRI differs by race and may be relevant for risk stratification and management counseling of PI-RADS 3 lesions.