Elsevier

European Urology

Volume 66, Issue 3, September 2014, Pages 430-436
European Urology

Platinum Priority – Prostate Cancer
Editorial by Mark Emberton on pp. 437–438 of this issue
Cost-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

https://doi.org/10.1016/j.eururo.2013.12.012Get rights and content

Abstract

Background

The current diagnostic strategy using transrectal ultrasound–guided biopsy (TRUSGB) raises concerns regarding overdiagnosis and overtreatment of prostate cancer (PCa). Interest in integrating multiparametric magnetic resonance imaging (MRI) and magnetic resonance–guided biopsy (MRGB) into the diagnostic pathway to reduce overdiagnosis and improve grading is gaining ground, but it remains uncertain whether this image-based strategy is cost-effective.

Objective

To determine the cost-effectiveness of multiparametric MRI and MRGB compared with TRUSGB.

Design, setting, and participants

A combined decision tree and Markov model for men with elevated prostate-specific antigen (>4 ng/ml) was developed. Input data were derived from systematic literature searches, meta-analyses, and expert opinion.

Outcome measurements and statistical analysis

Quality-adjusted life years (QALYs) and health care costs of both strategies were modelled over 10 yr after initial suspicion of PCa. Probabilistic and threshold analyses were performed to assess uncertainty.

Results and limitations

Despite uncertainty around the presented cost-effectiveness estimates, our results suggest that the MRI strategy is cost-effective compared with the standard of care. Expected costs per patient were €2423 for the MRI strategy and €2392 for the TRUSGB strategy. Corresponding QALYs were higher for the MRI strategy (7.00 versus 6.90), resulting in an incremental cost-effectiveness ratio of €323 per QALY. Threshold analysis revealed that MRI is cost-effective when sensitivity of MRGB is ≥20%. The probability that the MRI strategy is cost-effective is around 80% at willingness to pay thresholds higher than €2000 per QALY.

Conclusions

Total costs of the MRI strategy are almost equal with the standard of care, while reduction of overdiagnosis and overtreatment with the MRI strategy leads to an improvement in quality of life.

Patient summary

We compared costs and quality of life (QoL) of the standard “blind” diagnostic technique with an image-based technique for men with suspicion of prostate cancer. Our results suggest that costs were comparable, with higher QoL for the image-based technique.

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.

References (39)

  • A.H. Briggs et al.

    Model parameter estimation and uncertainty: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force—6

    Value Health

    (2012)
  • G. Draisma et al.

    Lead time and overdiagnosis in prostate-specific antigen screening: importance of methods and context

    J Natl Cancer Inst

    (2009)
  • H.G. Welch et al.

    Overdiagnosis in cancer

    J Natl Cancer Inst

    (2010)
  • I.J. Korfage et al.

    Five-year follow-up of health-related quality of life after primary treatment of localized prostate cancer

    Int J Cancer

    (2005)
  • E.A. Heijnsdijk et al.

    Overdetection, overtreatment and costs in prostate-specific antigen screening for prostate cancer

    Br J Cancer

    (2009)
  • E.A. Heijnsdijk et al.

    Quality-of-life effects of prostate-specific antigen screening

    N Engl J Med

    (2012)
  • V.A. Moyer

    Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement

    Ann Intern Med

    (2012)
  • K.M. Selnaes et al.

    Peripheral zone prostate cancer localization by multiparametric magnetic resonance at 3 T: unbiased cancer identification by matching to histopathology

    Invest Radiol

    (2012)
  • B. Turkbey et al.

    Prostate cancer: value of multiparametric MR imaging at 3 T for detection—histopathologic correlation

    Radiology

    (2010)
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