Cost-Effectiveness Analysis of Prostate-Specific Membrane Antigen (PSMA) Positron Emission Tomography/Computed Tomography (PET/CT) for the Primary Staging of Prostate Cancer in Australia

Abstract

Background and Objectives Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) combined with computed tomography (CT) is a new imaging modality to detect the extra-prostatic spread of prostate cancer. PSMA PET/CT has a higher sensitivity and specificity than conventional imaging (CT ± whole body bone scan [WBBS]). This study conducted a cost-utility analysis of PSMA PET/CT compared with conventional imaging for patients with newly diagnosed, intermediate-risk or high-risk primary prostate cancer. Perspective Australian healthcare perspective. Setting Tertiary. Methods A decision-analytic Markov model combined data from a variety of sources. The time horizon was 35 years. The sensitivity and specificity of PSMA PET/CT and CT alone were based on meta-analyses and the test accuracy of CT+WBBS was based on a single randomised controlled trial. Health outcomes included cases detected, life-years, and quality-adjusted life-years. Costs related to other diagnostic tests, initial treatment, adverse events, and post-disease progression were included. All costs were reported in 2021 Australian Dollars (A$). ResultsThe deterministic incremental cost-effectiveness ratio of PSMA PET/CT was estimated to be A $21,147/qualityadjusted life-year gained versus CT+WBBS, and A$36,231/quality-adjusted life-year gained versus CT alone. The results were most sensitive to the time horizon, and the initial treatments received by patients diagnosed with metastatic cancer. The probability of PSMA PET/CT being cost effective was estimated to be 91% versus CT+WBBS and 89% versus CT alone, using a threshold of AU$50,000/quality-adjusted life-year gained. Conclusions PSMA PET/CT is likely to be more costly than CT+WBBS or CT alone in Australia; however, it is still likely to be considered cost effective compared with conventional imaging.

Prostate-Specific Membrane Antigen PET-CT Imaging for the Staging of Prostate Cancer in Canada

“…5 Both gallium-68 (68Ga) and fluorine-18 (18F)-labelled PSMA-specific radiopharmaceuticals are clinically used to stage prostate cancer tumour cells with PET-CT. 6 A growing body of evidence [6][7][8][9] suggests that PSMA-directed PET (PSMA-PET) radiopharmaceuticals can determine different stages of cancer in the prostate with more specificity than conventional imaging such as CT, MRI, and bone scan, 10 and can detect spread to pelvic nodal or distant metastatic sites. 11 Accurate staging of prostate cancer before primary therapy can help guide treatment decisions, such as choices between surgery and radiation therapy, use of adjuvant hormone therapy, and design of therapeutic approaches, such as targeting suspicious lymph nodes for node dissection or radiotherapy. Additionally, in the setting of biochemical failure after primary treatment, accurate restaging can identify those with recurrence limited to the prostate, prostate bed, and/or pelvic lymph nodes where salvage therapies may still be potentially curative and where integration of local salvage surgery, radiotherapy, or other ablative techniques may avoid the need for lifelong palliative androgen deprivation therapy.…”

“…12 Imaging with PSMA-PET may also reduce adverse events by preventing unnecessary treatment and ultimately improve the quality of life and overall survival of patients. 11 Gallium-68 PSMA may also play a role in selecting patients who may benefit from targeted systemic radionuclide therapy; for example, Lutetium-177 PSMA-617, 13 which was approved by Health Canada in September 2022. 14 This therapy delivers beta-particle radiation to PSMA-expressing cells and the surrounding microenvironment and is intended to extend progression-free survival and overall survival when added to the standard of care in patients with advanced PSMA-positive metastatic castration-resistant prostate cancer.…”

“…Approximately 80% of PET-CT's overall use is dedicated to oncology exams, with some variation from province to province. For prostate cancer, there is variability across Canadian provinces and territories in accessing PET-CT. 11,17 As of 2021, 4 provinces do not currently fund the use of PET-CT in prostate cancer for any purpose, and 1 province funds the use of PET-CT in prostate cancer upon discussion with a nuclear medicine specialist. At least 5 provinces fund PSMA-PET as part of clinical trials.…”

“…6 A PET-CT exam is then performed in the imaging room, with an image acquisition time of between 20 and 40 minutes (Table 2). 50 Typically, 1 exam is required, 11 and the entire procedure takes approximately 2.5 hours.…”

Bone Scintigraphy versus PSMA-Targeted PET/CT or PET/MRI in Prostate Cancer: Lessons Learned from Recent Systematic Reviews and Meta-Analyses

“…Beyond the advantages in the diagnostic performance of PSMA-targeted PET/CT compared to bone scintigraphy in PC, recent high-quality studies have shown the better cost-effectiveness of PSMA-targeted PET/CT compared to conventional imaging (including bone scintigraphy) [ 21 , 22 ].…”