Abstract

PURPOSE: Many localized prostate cancers will follow an indolent course. Management has shifted towards active surveillance (AS), yet an optimal regimen remains controversial especially regarding expensive multiparametric magnetic resonance imaging (MRI). We aimed to assess cost-effectiveness of MRI in AS protocols.MATERIALS AND METHODS: A probabilistic microsimulation modeled individual patient trajectories for men diagnosed with low-risk cancer. We assessed no surveillance, up-front treatment (surgery or radiation), and scheduled AS protocols incorporating transrectal ultrasound-guided (TRUS) biopsy or MRI-based regimens at serial intervals. Lifetime quality-adjusted life years (QALYs) and costs adjusted to 2020-US$ were used to calculate expected net monetary benefit (NMB) at $50,000/QALY and incremental cost-effectiveness ratios (ICERs). Uncertainty was assessed with probabilistic sensitivity analysis and linear regression metamodeling.RESULTS: Conservative management with AS outperformed up-front definitive treatment in a modeled cohort reflecting characteristics from a multi-institutional trial. Biopsy decision conditional on positive imaging (MRI triage) at 2-year intervals provided the highest expected NMB (ICER $44,576). Biopsy after both positive and negative imaging (MRI pathway) and TRUS-based regimens were not cost-effective. MRI triage resulted in fewer biopsies while reducing metastatic disease or cancer death. Results were sensitive to test performance and cost. MRI triage was the most likely cost-effective strategy on probabilistic sensitivity analysis.CONCLUSIONS: For men with low-risk prostate cancer, our modeling demonstrated that AS with sequential MRI triage is more cost-effective than biopsy regardless of imaging, TRUS biopsy alone, or immediate treatment. AS-guidelines should specify the role of imaging, and prospective studies should be encouraged.

View details for DOI 10.1097/JU.0000000000002490

View details for PubMedID 35212570