Optimising the Diagnosis of Prostate Cancer in the Era of Multiparametric Magnetic Resonance Imaging: A Cost-effectiveness Analysis Based on the Prostate MR Imaging Study (PROMIS)

Abstract

BackgroundThe current recommendation of using transrectal ultrasound-guided biopsy (TRUSB) to diagnose prostate cancer misses clinically significant (CS) cancers. More sensitive biopsies (eg, template prostate mapping biopsy [TPMB]) are too resource intensive for routine use, and there is little evidence on multiparametric magnetic resonance imaging (MPMRI).ObjectiveTo identify the most effective and cost-effective way of using these tests to detect CS prostate cancer.Design, setting, and participantsCost-effectiveness modelling of health outcomes and costs of men referred to secondary care with a suspicion of prostate cancer prior to any biopsy in the UK National Health Service using information from the diagnostic Prostate MR Imaging Study (PROMIS).InterventionCombinations of MPMRI, TRUSB, and TPMB, using different definitions and diagnostic cut-offs for CS cancer.Outcome measurements and statistical analysisStrategies that detect the most CS cancers given testing costs, and incremental cost-effectiveness ratios (ICERs) in quality-adjusted life years (QALYs) given long-term costs.Results and limitationsThe use of MPMRI first and then up to two MRI-targeted TRUSBs detects more CS cancers per pound spent than a strategy using TRUSB first (sensitivity = 0.95 [95% confidence interval {CI} 0.92–0.98] vs 0.91 [95% CI 0.86–0.94]) and is cost effective (ICER = £7,076 [€8350/QALY gained]). The limitations stem from the evidence base in the accuracy of MRI-targeted biopsy and the long-term outcomes of men with CS prostate cancer.ConclusionsAn MPMRI-first strategy is effective and cost effective for the diagnosis of CS prostate cancer. These findings are sensitive to the test costs, sensitivity of MRI-targeted TRUSB, and long-term outcomes of men with cancer, which warrant more empirical research. This analysis can inform the development of clinical guidelines.Patient summaryWe found that, under certain assumptions, the use of multiparametric magnetic resonance imaging first and then up to two transrectal ultrasound-guided biopsy is better than the current clinical standard and is good value for money.

Cost‐effectiveness of magnetic resonance imaging and targeted fusion biopsy for early detection of prostate cancer

“…Faria et al. recently published a cost‐effectiveness study based on the Prostate MR Imaging Study (PROMIS) based in the UK and found that performing multiparametric MRI followed by up to two targeted TRUS‐guided biopsies was a cost‐effective approach to early detection of PCa, reaching a similar conclusion to that of the present study.…”

Value of MRI in medicine: More than just another test?

“…In the last 6 months alone there have been two prospective studies demonstrating the value of both MP and bp‐MRI at either 1.5T or 3T, multiparametric of biparametric with either typical protocol length or abbreviated (15 min) can, in certain groups of men, reduce the need for prostate biopsy by 24–27% (Fig. ), or increased the yield of biopsy compared to transrectal ultrasound (TRUS)‐guided biopsy …”

“…8), or increased the yield of biopsy compared to transrectal ultrasound (TRUS)guided biopsy. 34,35 Brain Neurological imaging is one of the commonest MRI exams and there are multiple neurological applications of rapid MR protocols, and three representative examples are discussed here. These include a single-shot T 2 -weighted fast spin echo (FSE) sequence, which takes 3 minutes of exam time, for assessing hydrocephalus and shunt tip location in children.…”

Advancing Biomarker Development Through Convergent Engagement: Summary Report of the 2nd International Danube Symposium on Biomarker Development, Molecular Imaging and Applied Diagnostics; March 14–16, 2018; Vienna, Austria

“…Because any additional costs imposed on the healthcare system means that these resources cannot be used in other ways, some health is lost or foregone (aka Bhealth opportunity costs^). With regard to diagnostic tests, HTA often considers not only which test should be used in clinical practice but also how the test should be used, that is, what is the best way to proceed, clinically, using the information it provides [124,[129][130][131][132].…”