Platinum Priority – Prostate CancerEditorial by Mark Emberton on pp. 437–438 of this issueCost-effectiveness of Magnetic Resonance (MR) Imaging and MR-guided Targeted Biopsy Versus Systematic Transrectal Ultrasound–Guided Biopsy in Diagnosing Prostate Cancer: A Modelling Study from a Health Care Perspective
Introduction
Systematic 10- to 12-core transrectal ultrasound–guided biopsy (TRUSGB) is the most accepted method for making a definite diagnosis of prostate cancer (PCa) in men with an increased serum prostate-specific antigen (PSA) or abnormal digital rectal examination (DRE). Although advances have been made since the average number of TRUSGB cores has increased from 6 to 12 [1], the probability of detecting PCa is still subject to random error because the operator cannot reliably visualise tumour.
The current TRUSGB diagnostic pathway is limited because of overdiagnosis and subsequent overtreatment of PCa [2], [3], [4] and is accompanied by a risk of postbiopsy infection [5], [6]. This limitation may in turn lead to elevated psychological, clinical, and economic impacts [7], [8], the main reason the US Preventive Services Task Force alerted the medical community to the dangers of PSA testing [9]. Therefore, the potential benefits of diagnosing PCa must be weighed against the risks, reinforcing the need for better pretreatment characterisation of PCa.
Multiparametric magnetic resonance imaging (mp-MRI) has emerged as an imaging technique that has the ability to accurately characterise PCa. This technology has led to opportunities to improve the diagnostic pathway [10], [11]. With mp-MRI and subsequently magnetic resonance–guided biopsy (MRGB), cancer-suspicious areas can be targeted [12]. As with mp-MRI, predominantly significant PCa is seen and insignificant cancer is not diagnosed, so this technique has the potential to solve the problem of overdiagnosis and overtreatment of the current TRUSGB pathway [13], [14]. In addition, MRGB confers the ability to reduce unnecessary prostate biopsies by approximately 30–60% [15], [16] using fewer biopsy cores (2–4 vs 10–12) [16].
Prospective trials are currently performed to determine the definite diagnostic role of mp-MRI and MRGB compared with the current standard of TRUSGB, but the decision regarding which diagnostic strategy to use should not be based on diagnostic accuracy alone. Costs related to performance and the therapeutic consequences of the test should also be taken into consideration [17]. In addition, it is important to look at other (in)direct consequences, such as quality of life (QoL) and survival. We therefore developed a decision analytic model to assess from a health care perspective the cost-effectiveness of the magnetic resonance imaging (MRI) strategy (mp-MRI followed by MRGB) versus the standard TRUSGB strategy in diagnosing PCa.
Section snippets
Model development
We developed a decision analytic model to evaluate diagnostic accuracy, QoL, survival, and costs associated with two strategies for diagnosing PCa in patients with an elevated PSA level (>4 ng/ml). The model consisted of a decision tree combined with a Markov model (see Supplemental Fig. 1). Based on published clinical guidelines and expert opinion, a typical clinical setting was created. The first strategy is the current standard of care, where an elevated serum PSA is followed by systematic
Cost-effectiveness of magnetic resonance imaging and magnetic resonance–guided biopsy compared with transrectal ultrasound–guided biopsy
The results show that the expected costs of the MRI strategy (€2423; 95% confidence interval [CI], €2219–2637) were €31 higher than those for the TRUSGB strategy (€2392; 95% CI, €2227–2563; Table 4). The corresponding QALYs were 0.10 higher for the MRI strategy (7.00; 95% CI, 3.72–8.32) compared with the TRUSGB strategy (6.90; 95% CI, 3.84–8.22) but with considerable uncertainty in these findings, as the CIs reflect. This resulted in an ICER of €323 per QALY gained.
Sensitivity analysis
The probability that the MRI
Discussion
The results of our model suggest that the MRI strategy is cost-effective in diagnosing PCa compared with the TRUSGB strategy, assuming a sensitivity of MRGB ≥20%. Although the MRI strategy is initially more expensive, these extra costs are compensated for by reducing treatment costs resulting from fewer false positives and a better estimation of tumour aggressiveness. The improvement in QALYs is achieved by preventing unnecessary radical treatment of insignificant tumours (with a reduced QoL
Conclusions
Our results suggest that the MRI strategy is cost-effective compared with the standard of care using TRUSGB, despite uncertainty around the presented cost-effectiveness estimates. The total costs of the MRI strategy are almost equal with standard of care, while potential reduction of overdiagnosis and overtreatment with the MRI strategy leads to an improvement in the QoL of PCa patients.
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2022, Value in Health Regional IssuesCitation Excerpt :In addition, there was some variation in the types of MRI biopsy strategies and techniques (cognitive, in-bore, and MRI/TRUS fusion) assessed. In these studies, intervention included MRI-US fusion targeted biopsy,18,19 cognitive-targeted biopsy,14,24,25 direct in-bore MRI-guided biopsy,17 and both cognitive and MRI/TRUS fusion biopsy.26 Some studies found that the results were sensitive to survival after castration-sensitive PCa treatment and survival with catheter intraperitoneal chemotherapy,27 test costs and longer costs for men with cancer,24,25 the sensitivity of MRI-targeted TRUSGB,17,24,25 and long-term outcomes of men with cancer.24,25
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2022, Value in HealthCitation Excerpt :In comparison, the only health states modeled in Faria et al30 were progression free and metastatic cancer. A total of 8 studies modeled survival time from diagnosis only,19,25,26,33,38,39,41,46 with no progression through health states. A total of 4 did not model beyond diagnosis.14,16,22