MRI less cost-effective than PSA as first-line testing for prostate cancer

Screening for prostate cancer using biparametric magnetic resonance imaging (MRI) as a first-line approach is less cost-effective than first-line prostate-specific antigen (PSA) testing with second-line multiparametric MRI, a cost-effectiveness analysis found.

Researchers developed a microsimulation model to evaluate the effectiveness and costs of first-line biparametric MRI compared to first-line PSA with reflex multiparametric MRI for prostate cancer screening. The model assumed biennial screening to age 69 years using first-line PSA testing (test-positive threshold, 4 mg/L) with or without second-line multiparametric MRI or first-line biparametric MRI (test-positive threshold, PI-RADS [Prostate Imaging Reporting and Data System] score of 3 to 5 or 4 to 5), followed by biopsy guided by MRI or MRI plus transrectal ultrasonography. The results of the analysis were published June 4 by Annals of Internal Medicine.

First-line MRI-based screening substantially increased rates of false-positive tests, prostate biopsy, and overdiagnosis without proportionate reductions in prostate cancer mortality, the study found. For 1,000 men, first-line biparametric MRI versus first-line PSA testing prevented two to three prostate cancer deaths and added 10 to 30 life-years (4 to 11 days per person). However, the number of biopsies rose by 1,506, while the number of overdiagnoses rose by 38 to 124 depending on the biopsy imaging scheme. At conventional cost-effectiveness thresholds, first-line PSA testing with multiparametric MRI followed by either biopsy approach produced the greatest net monetary benefits, the authors wrote.

The authors also noted that even when assuming no cost for first-line biparametric MRI screening, first-line PSA testing with reflex multiparametric MRI followed by MRI-guided prostate biopsy with or without transrectal ultrasonography-guided biopsy still resulted in lower costs and better quality of life.

An accompanying editorial said that high-quality cost-effectiveness analyses are crucial to understanding how changes in clinical practice affect the overall health care system.

"Ultimately, this thoughtful cost-effectiveness analysis of a [biparametric] MRI-first prostate cancer screening approach highlights the need for a more robust understanding of the true comparative diagnostic accuracy of [biparametric] MRI compared with PSA testing followed by standard template biopsy, the financial toxicity associated with modern prostate cancer screening practices, and how to select the best patients for prostate biopsy through incorporation of biomarkers, imaging, and patient risk factors," the editorial stated. "While we await such evidence, rigorous cost-effectiveness analyses can and should be considered in guideline recommendations to encourage physicians to pursue the highest-value management strategy for their patients."

Another recent study, published by JAMA on May 30, found that protocol-directed active surveillance was a safe management strategy for avoiding overtreatment and preventing undertreatment of prostate cancer. The multicenter cohort study included 2,155 men with favorable-risk prostate cancer and no prior treatment who were enrolled at 10 North American centers through August 2022 and underwent active surveillance for prostate cancer. Patients were followed using a standardized protocol in which PSA was measured every three months before 2020 and every six months starting in 2020. Prostate biopsies were done by protocol six to 12 months after diagnosis, two years after diagnosis, and then every two years, with biopsies done within 12 months of the target date considered compliant. Ten years after diagnosis, 49% of men remained free of progression or treatment, less than 2% developed metastatic disease, and less than 1% died from it. There was no significant difference in adverse outcomes in men treated within the first two years of surveillance compared to later. The authors concluded that active surveillance is an effective management strategy for patients diagnosed with favorable-risk prostate cancer.