Prostate-specific antigen screening more cost effective than first-line MRI

Key takeaways:

• First-line biparametric MRI testing increased the number of biopsies and overdiagnoses vs. first-line PSA screening.
• Biparametric MRI was less cost effective, even when it was assumed to be free.

First-line prostate-specific antigen testing with second-line multiparametric MRI was a more cost effective screening strategy for prostate cancer than biparametric MRI as a first-line approach, a study showed.

Prior research has tied prostate-specific antigen (PSA) screening for prostate cancer with high rates of overdiagnoses and limited reductions in cancer-specific mortality, Roman Gulati, MS, from the Fred Hutchinson Cancer Center, and colleagues wrote in Annals of Internal Medicine.

Additionally, screening strategies that used multiparametric MRI (mpMRI) as a second-line test for men with high PSA require “a two-step evaluation, often necessitating multiple office visits and urologic consultation,” they wrote.

Meanwhile, biparametric MRI (bpMRI) has emerged as a potential first-line alternative to PSA, although “uncertainty remains about the expected mortality reduction, overdiagnosis, and cost-effectiveness” of the screening in addition to questions about the feasibility of its implementation, the researchers noted.

Gulati and colleagues used a microsimulation model to assess the cost effectiveness and comparative effectiveness between first-line bpMRI and first-line PSA with a possible reflex mpMRI, followed by different biopsy imaging schemes.

The model simulated a cohort of men aged 55 years who had no prior screening or prostate cancer diagnoses, underwent biennial screening until age 69 years and who were followed until age 100 years.

For 1,000 men, first-line bpMRI prevented two to three prostate cancer deaths and added 10 to 30 life-years — or 4 to 11 days per person — compared with first-line PSA testing.

However, first-line bpMRI also increased the number of biopsies by 1,506 and the number of overdiagnoses by 38.

The researchers also found that first-line bpMRI was not cost effective, even if the test came at no cost. Instead, first-line PSA and second-line mpMRI, followed by MRI-guided prostate biopsy with or without transrectal ultrasonography-guided biopsy, resulted in lower costs and greater quality of life in patients.

“Our analysis suggests that the expense of first-line bpMRI strategies is driven by the downstream consequences of false-positive results and overdiagnoses,” they wrote.

Still, first-line bpMRI remains “promising” despite the findings, Gulati and colleagues pointed out.

“It is less costly and faster to perform than mpMRI, and several studies support its comparative utility in this setting,” they wrote.

There were several limitations to the study, according to the researchers. For example, other characteristics that impact the performance of MRI-based screenings may not have been captured by the model.

Ultimately, “screening efforts should focus on strategies that reduce false-positive results and overdiagnoses to improve cost effectiveness,” Gulati and colleagues concluded.

In a related editorial, Daniel D. Joyce, MD, MS, an assistant professor in the department of urology at Vanderbilt University Medical Center, and colleagues noted that the most cost effective screening strategy in the study was not PSA alone, but PSA followed by MRI-targeted or standard template biopsies.

“As such, high-value prostate cancer screening remains a nuanced process that likely benefits from thoughtful incorporation of MRI,” they wrote.

They also wrote that cost effectiveness analyses “are crucial to understanding the effect of changes in clinical practice on the overall health care system.”

“They provide important economic context, which is often ignored in the development of guideline statements,” they wrote. “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.”

References:

• Gulati R, et al. Ann Intern Med. 2024;doi:10.7326/M23-1504.
• Joyce D, et al. Ann Intern Med. 2024;doi:10.7326/M24-0878.