The cost of mpMRI on active surveillance is often a factor in its use in a routine setting. Although the cost in some health care systems is high, it can be offset against the cost savings generated by delaying or avoiding surgery or other treatments. Gordon and colleagues [37] have evaluated the cost-effectiveness of mpMRI to diagnose prostate cancer and direct all low-risk patients to active surveillance. They developed a cohort model in three different scenarios (i.e. (i) no mpMRI but only active surveillance, (ii) mpMRI and active surveillance in a biopsy-naïve population and (iii) mpMRI and increased active surveillance uptake) and concluded that mpMRI and active surveillance in men with low-risk prostate cancer are strongly cost-effective (likelihood of 86.9%). For every 1000 men suspected of prostate cancer, using mpMRI could avoid 340 biopsies, detect an additional 20 significant cancers and detect 10 fewer insignificant cancers. However, this only addresses the use of a single mpMRI scan prior to first biopsy and not the use of follow-up mpMRI whilst on active surveillance. This would require an additional evaluation, in light of whether other tests (e.g. routine rebiopsy) could be omitted .

There is good evidence to support the use of mpMRI in men with an initial biopsy suitable for active surveillance, and to target any lesions seen on mpMRI, often in conjunction with a confirmatory systematic biopsy.

MpMRI may offer an opportunity to follow men on active surveillance without the need of performing further biopsies, in the absence of signs of progression. Although mpMRI is of interest for the monitoring of men on active surveillance, robust data from prospective studies are needed before widespread adoption of mpMRI can replace repeat biopsies.