KLK3 and cancer: Over the study period, biopsy outcomes improved: detection of International Society of Urological Pathology [ISUP] grade group [GG] ≥2 cancers more than doubled (RR: 2.12; 95% CI: 1.99-2.27), whereas both benign biopsies (RR: 0.66; 95% CI: 0.62-0.69) and ISUP GG 1 (RR: 0.61; 95% CI: 0.54-0.69) declined markedly.<h4>Conclusions and clinical implications</h4>PSA testing remained prevalent, and pre-biopsy MRI use increased substantially.