BERKELEY, CA (UroToday.com) - Systematic 10-12 core transrectal ultrasound-guided biopsy (TRUSGB) in men with elevated PSA and/or abnormal digital rectal examination can lead to over-diagnosis and subsequent over-treatment of indolent prostate cancer (PCa), but also to under-diagnosis of significant PCa. These limitations may have psychological, clinical, and economic impacts – the main reason for the U.S. Preventive Services Task Force (USPSTF) to alert the medical community to the dangers of PSA testing.
Multiparametric magnetic resonance imaging (mpMRI) has emerged as an imaging technique with the ability to accurately characterize PCa, and enables targeted MR-guided biopsy (MRGB) in cancer-suspicious areas. As with mpMRI, predominantly significant PCa is seen and indolent cancer is not diagnosed; this technique has the potential to solve the problems of the current TRUSGB-driven diagnostic pathway.
Prospective trials are currently being performed to determine the definite diagnostic role of mpMRI and MRGB in men with a suspicion of prostate cancer. However, the decision regarding which diagnostic strategy is preferred should not be based on diagnostic accuracy alone. Costs related to the performance, and the therapeutic consequences of the test, should also be taken into consideration. In addition, it is important to look at other (in)direct consequences, such as quality of life and survival. In this study we developed a decision-analytic model to assess the cost-effectiveness of the MRI strategy (mpMRI followed by MRGB) compared with the standard TRUSGB strategy.
Input data for the combined decision tree and Markov model were derived from systematic literature searches, meta-analyses, and expert opinion. For both strategies, quality-adjusted life years (QALYs) and health care costs were modelled over 10 years after initial suspicion of PCa.
Expected costs per patient were €2423 for the MRI strategy and €2392 for the TRUSGB strategy. Corresponding QALYs were higher for the MRI strategy (6.98 versus 6.89), resulting in an incremental cost-effectiveness ratio of €323/QALY. Threshold analysis revealed MRI is cost-effective when sensitivity of MRGB is 20% or higher. Taking into account the existing uncertainty, the probability that the MRI strategy is cost-effective is around 80% at willingness to pay thresholds over €2.000/QALY.
The results of our decision analytic model suggest that the mpMRI strategy is a cost-effective strategy compared to the standard of care using TRUSGB, despite uncertainty around the presented cost-effectiveness estimates. While the mpMRI strategy is initially more expensive, these extra costs are compensated for by reduced treatment costs and improved quality of life due to fewer false positives and less unnecessary aggressive treatments.
Written by:
Maarten de Rooij as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
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