First-line PSA testing with mpMRI found more cost-effective than first-line bpMRI

Findings from a recent study indicate that prostate cancer screening strategies based on first-line biparametric MRI (bpMRI) are less cost-effective than first-line prostate-specific antigen (PSA) testing followed by reflex multiparametric (mpMRI).^1,2

The study assessed clinical outcomes for 1000 men across 9 different screening strategies.

Data from the study showed that while bpMRI-based screening methods led to fewer prostate cancer deaths vs PSA plus mpMRI, bpMRI approaches were less cost effective due to increased false-positive results and overdiagnosis of prostate cancer.

Lead author, Roman Gulati, MS, commented in correspondence with Urology Times®, “The main question we studied was ‘What is the comparative effectiveness and cost-effectiveness of front-line bpMRI compared to front-line PSA testing with or without reflex MRI testing to screen for prostate cancer?’ To answer this question, we used a decision analysis based on a microsimulation model of prostate cancer natural history, diagnosis, treatment, and survival. We superimposed on this model regular first-line bpMRI and first-line PSA testing strategies, which were represented using published or derived performance characteristics to project outcomes over a lifetime time horizon.”

Overall, data from the study showed that first-line bpMRI strategies prevented 2 to 3 prostate cancer deaths and added 10 to 30 life-years (4 to 11 days per person) compared with first-line PSA-based strategies. Strategies with first-line bpMRI were also shown to reduce the number of false-negative biopsy referrals.

However, first-line bpMRI approaches increased total biopsy referrals and false-positive biopsy referrals compared with approaches using first-line PSA screening with or without mpMRI. Specifically, strategies using first-line bpMRI increased the number of biopsies by 1506 to 4174 and the number of overdiagnoses by 38 to 124 vs strategies with first-line PSA.

The qualitative conclusions did not differ based on the cost of bpMRI; even when offered at no cost, first-line bpMRI-based screening was found to be less cost-effective than first-line PSA-based strategies. The authors found that screening with first-line PSA plus mpMRI followed by either biopsy approach (magnetic resonance imaging-guided biopsy [MRGB] or MRGB + transrectal ultrasonography–guided biopsy) for PI-RADS 4 to 5 lesions produced the greatest monetary benefits, according to conventional cost-effectiveness thresholds. This approach was also shown to produce the highest quality-adjusted life years compared with other methods.

Overall, the study assessed clinical outcomes for 1000 men simulated across 9 different screening strategies. Men studied were aged 55 to 69 years and had not received prior screening or a diagnosis of prostate cancer.

In an accompanying editorial on the study, authors from Vanderbilt University suggest that guideline statements should take into account the economic context in their recommendations for screening methods, which has already been done by the National Comprehensive Cancer Network. They further suggest that this study highlights the need for more data on the comparative accuracy of bpMRI vs PSA testing followed by biopsy as well as the financial toxicities associated with different screening methods.³

Gulati concluded, “We found that front-line bpMRI led to fewer prostate cancer deaths compared to front-line PSA testing, but it also led to many more false positives and overdiagnoses. Consequently, we found that front-line bpMRI was not cost-effective compared to front-line PSA testing. We concluded that to improve cost-effectiveness, prostate cancer screening strategies should focus on reducing false positives and overdiagnosis.”

References

1. Gulati R, Jiao B, Al-Faouri R, et al. Lifetime health and economic outcomes of biparametric magnetic resonance imaging as first-line screening for prostate cancer : A decision model analysis. Ann Intern Med. Published online ahead of print June 4, 2024. Accessed June 10, 2024. doi:10.7326/M23-1504

2. Screening for prostate cancer with first-line MRI less cost-effective than first-line PSA testing. News release. American College of Physicians (ACP). May 28, 2024. Accessed June 10, 2024. https://www.newswise.com/articles/screening-for-prostate-cancer-with-first-line-mri-less-cost-effective-than-first-line-psa-testing

3. Joyce DD, Talwar R, Moses KA. The cost-effectiveness of prostate cancer screening that incorporates magnetic resonance imaging. Ann Intern Med. Published online ahead of print June 4, 2024. Accessed June 10, 2024. doi:10.7326/M24-0878