Analysis supports prebiopsy MRI with prostate cancer screening

Prostate cancer screening involving a prebiopsy MRI was linked to an improvement in both benefit-harm and cost-effectiveness profiles compared with biopsy-first screening, according to an analysis published in JAMA Network Open.^1,2

The analysis, which was a modelling study involving a hypothetical cohort of 4.5 million men, found that the benefits were greatest when using risk-stratified screening based on polygenic risk profile and age. The model predicted that using an MRI-first, aged-based screening pathway would lead to 0.9% (1368) fewer deaths from prostate cancer, 14.9% (12,370) fewer overdiagnoses, and 33.8% (650,500) fewer biopsies compared with biopsy-first aged-based screening.

At a 10-year absolute risk threshold of 2%, MRI-first risk-stratified screening was associated with 10.4% (7335) fewer overdiagnosed cancers and 21.7% (412,100) fewer MRIs than MRI-first aged-based screening. At a 10-year absolute risk threshold of 10%, MRI-first risk-stratified screening was associated with 72.6% (51,250) fewer overdiagnosed cancers and 53.5% (1,016,000) fewer biopsies compared with MRI-first age-based screening.

Regarding costs, first author Thomas Callender, MBChB, MSc, and his coinvestigators at University College London (UCL) wrote, “An MRI-first approach was associated with more QALYs at reduced costs compared with a biopsy-first diagnostic pathway,” adding that, “The most cost-effective strategies at willingness-to-pay thresholds of £20 000 (US $26 000) and £30 000 (US $39 000) per quality-adjusted life-year gained were MRI-first risk-stratified screening at 10-year absolute risk thresholds of 8.5% and 7.5%, respectively.”

Commenting on the results in a press release, co-author, Mark Emberton, MBBS, MD, UCL Dean of the Faculty of Medical Sciences, stated, “Our study shows that screening for prostate cancer—which could save between 16% and 20% of prostate cancer deaths—might be possible with targeted screening using genetic risk and MRI as part of the diagnostic pathway. This paves the way for further clinical trials to study the real-world implementation of such a screening program.”

For their study, Callender et al’s hypothetical cohort of 4.5 million men was modelled after the number of men in England who are aged 55 to 69 years. They simulated health outcomes based on these individuals receiving “age-based” or “risk-tailored” screening programs, with follow-up extending to 90 years of age.

The age-based model involved all men aged 55 to 69 years undergoing PSA-based screening every 4 years. If a man had a positive PSA test, the algorithm would follow with an MRI and, when required, a biopsy. In the risk-tailored pathway, men were only screened with a PSA test (with MRI and biopsy if necessary) if their risk status—based on polygenic risk score and age—reached a predetermined level.

In an accompanying editorial simultaneously published in JAMA Network Open, Michael Borre, MD, PhD, DrMedSci, department of Urology, Aarhus University Hospital, Aarhus, Denmark, wrote, “An MRI-first risk-stratified screening program, including implementation research, needs prospective evaluation. Meanwhile, clinicians must rely on existing guidelines supplied with well-substantiated analytic decision models, like the model by Callender et al.

“Commendably, this decision analytical model is based on parameter estimates from available randomized clinical trials and likely reflects how a real-world screening program would occur. With an increasing responsibility for decision-making in clinical practice, decision-making models must be expected to be continuously updated and to incorporate the latest clinical advances, such as a PSA-density stratification of MRI lesions and targeted biopsy strategies.”³

References

1. Callender T, Emberton M, Morris Stephen et al. Benefit, harm, and cost-effectiveness associated with magnetic resonance imaging before biopsy in age-based and risk-stratified screening for prostate cancer. JAMA Netw Open. 2021;4(3):e2037657. doi: 10.1001/jamanetworkopen.2020.37657

2. Targeted screening for prostate cancer could prevent one in six deaths. Published online March 11, 2021. Accessed March 16, 2021. https://bit.ly/3txZCLv.

3. Borre M, et al. Prostate cancer screening—the need for and clinical relevance of decision analytical models. JAMA Netw Open. 2021;4(3):e212182. doi:10.1001/jamanetworkopen.2021.2182