Background: NCCN very low risk (VLR) prostate cancer is frequently clinically insignificant and thus over-diagnosed. Use of MRI prior to patient selection for prostate biopsy and to inform biopsy targeting can reduce the diagnosis of VLR disease. Indeed, a recent publication has reported no VLR diagnoses since 2018. We sought to better understand the incidence of VLR disease in our multi-hospital institutional cohort. Methods: We retrospectively identified 3197 patients who were newly diagnosed with prostate cancer at our eleven-hospital system from January 2018 – June 2023. Within this cohort, we identified patients who met VLR criteria. Patient clinical, pathological, and imaging characteristics were collected for analysis. Biopsies were considered MRI-informed if MRI was performed within two years prior to prostate biopsy. Biopsies were considered targeted if at least one region of interest was designated on pathology. Patients who had incomplete clinical records (n=2) were excluded from analysis. Active surveillance as initial disease management was defined as no treatment within one year of diagnosis. Welch’s two-sample t-test, Pearson’s chi-squared test, and Fisher’s exact tests were performed to compare clinical characteristics. PSA was log transformed for analysis. Results: In the study period, 11% (351/3195) of men diagnosed with prostate cancer were classified as NCCN very low risk. The incidence of VLR diagnoses was steady from 2018-2023 (p=0.8) despite increased usage of MRI-informed biopsies (p<0.001). Use of MRI-informed biopsy was similar for detection of VLR and higher risk disease (68% vs 72%, p=0.07). Of VLR patients who received a targeted biopsy, 69% (127/184) of disease was found in systematic regions only, 21% (39/184) was found in targeted regions only, and 10% (18/184) was found both systematically and in targeted regions. On multivariable analysis, black race, logPSA, and PIRADS 4 and 5 regions were negatively associated with VLR disease (Table). 86% (304/351) of VLR patients chose active surveillance as their initial disease management. Conclusions: VLR disease comprises a significant minority of prostate cancer diagnoses. The incidence of VLR has remained unchanged despite increased utilization of MRI-informed biopsies in our hospital system. In the majority of cases the diagnosis of VLR is made from the template biopsy (whether MRI-informed or not). Patients should, and frequently do, choose active surveillance to manage their disease. Use of nomograms and limiting biopsy of PI-RADS 3 lesions may decrease the incidence of VLR prostate cancer.