Biparametric MRI as initial screening method less cost-effective for prostate cancers compared to screening with PSA: Study

A new study published in the Annals of Internal Medicine suggests that a cost-effectiveness analysis revealed that using biparametric magnetic resonance imaging (MRI) as the initial screening method for prostate cancer is less cost-efficient when compared to starting with prostate-specific antigen (PSA) testing followed by multiparametric MRI as a second step.

The research team developed a microsimulation model to assess the effectiveness and costs of using first-line biparametric MRI versus first-line PSA with subsequent multiparametric MRI for prostate cancer screening. The model simulated biennial screening up to age 69 after comparing initial PSA testing (positive threshold of 4 mg/L) with or without second-line multiparametric MRI against first-line biparametric MRI (positive threshold PI-RADS score of 3 to 5 or 4 to 5), followed by biopsy guided by MRI or MRI plus transrectal ultrasonography.

The key findings of this study indicated that first-line MRI-based screening significantly increased the rates of false-positive tests, prostate biopsies, and over diagnosis without correspondingly reducing prostate cancer mortality. For every 1,000 men screened, first-line biparametric MRI prevented 2 to 3 prostate cancer deaths and added 10 to 30 life-years (equivalent to 4 to 11 days per person). However, it also resulted in 1,506 additional biopsies and 38 to 124 more over diagnoses, depending on the biopsy imaging scheme. The study found that, at conventional cost-effectiveness thresholds, first-line PSA testing followed by multiparametric MRI and either biopsy method yielded the highest net monetary benefits.

The study also observed that even if first-line biparametric MRI screening were free, first-line PSA testing with subsequent multiparametric MRI, followed by MRI-guided prostate biopsy with or without transrectal ultrasonography-guided biopsy, still proved to be more cost-effective and resulted in better quality of life. An accompanying editorial emphasized the importance of high-quality cost-effectiveness analyses in understanding the impact of changes in clinical practice on the overall healthcare system.

The decision analysis indicated that the comparative effectiveness and cost-effectiveness of prostate cancer screening are influenced by false-positive results and over diagnoses, making first-line PSA testing followed by multiparametric MRI more favorable than first-line biparametric MRI. Overall, this detailed cost-effectiveness analysis of a biparametric MRI-first approach for prostate cancer screening underlines the necessity for a deeper understanding of the true comparative diagnostic accuracy of biparametric MRI versus PSA testing followed by standard template biopsy. It also emphasized the importance of assessing the financial burden of contemporary prostate cancer screening practices and determining the best candidates for prostate biopsy by integrating biomarkers, imaging and patient risk factors.

Source:

Gulati, R., Jiao, B., Al-Faouri, R., Sharma, V., Kaul, S., Fleishman, A., Wymer, K., Boorjian, S. A., Olumi, A. F., Etzioni, R., & Gershman, B. (2024). Lifetime Health and Economic Outcomes of Biparametric Magnetic Resonance Imaging as First-Line Screening for Prostate Cancer. In Annals of Internal Medicine. American College of Physicians. https://doi.org/10.7326/m23-1504