Optimising the diagnosis of prostate cancer in the era of multi-parametric magnetic resonance imaging: a cost-effectiveness analysis based on the PROMIS study : How to optimise the diagnosis of prostate cancer

摘要

Background: The current recommendation of using transrectal ultrasound guided biopsy (TRUSB) to diagnose prostate cancer misses clinically significant (CS) cancers. More sensitive biopsies (e.g. template mapping biopsy (TPMB)) are too resource intensive for routine use and there is little evidence on multiparametric magnetic resonance imaging (MPMRI). Objective: To identify the most effective and cost-effective way of using these tests to detect CS prostate cancer. Design, setting, and participants: Cost-effectiveness modelling of health outcomes and costs of men referred to secondary care with suspicion of prostate cancer prior to any biopsy in the UK National Health Service using information from the PROMIS diagnostic study. Intervention(s): Combinations of MPMRI, TRUSB and TPMB, using different definitions and diagnostic cut-offs for CS cancer. Outcome Measurements and Statistical Analysis: Strategies that detect the most CS cancers given testing costs; incremental cost-effectiveness ratios (ICERs) in quality adjusted life years (QALYs), given the long-term costs. Results and Limitations: Using MPMRI first then up to two MPMRI-targeted TRUSB detects more CS cancers per pound spent than a strategy using TRUSB first (sensitivity=0.95 (95% confidence interval (CI) 0.92 to 0.98 vs. 0.91 (95% CI 0.86 to 0.94)) and is cost-effective (ICER=£7,076(€8,350/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. Conclusions: An MPMRI first strategy is effective and cost-effective for the diagnosis of CS prostate cancer. These findings are sensitive to the test costs, the sensitivity of MPMRI-targeted TRUSB and the long-term outcomes of men with cancer, which warrant more empirical research. This analysis can inform the development of clinical guidelines. Patient summary: We found that, under certain assumptions, using MPMRI first then up to two TRUSB is better than the current clinical standard and is good value for money.