Stella K. Kang, MD of the Departments of Radiology, NYU Langone Health speaks about Active Surveillance Strategies for Low-Grade Prostate Cancer: Comparative Benefits and Cost-effectiveness.
Link to Abstract:
https://pubs.rsna.org/doi/10.1148/radiol.2021204321
Overview:
Backdrop:
For low-risk prostate cancer, active surveillance (AS) is the preferred therapeutic strategy (PC). Surveillance varies by MRI, follow-up frequency, and the Prostate Imaging Reporting and Data System (PI-RADS) score, which determines whether or not a biopsy should be repeated.
Intention:
The goal of this study was to assess the efficacy and cost-effectiveness of AS methods for low-risk PC with and without MRI.
Components and Procedures:
In this work, researchers created a mathematical model to assess the cost-effectiveness of monitoring techniques in a simulation of males with low-risk PC. Watchful waiting, prostate-specific antigen (PSA) and yearly biopsy without MRI, and PSA testing with MRI with various PI-RADS thresholds for biopsy were all compared. The utilization of a PI-RADS score of at least 3, or a PI-RADS score of at least 4, to signal the necessity for biopsy differed amongst MRI methods. Microsimulation was used to compute life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Sensitivity analysis was done to see how different parameter values affected the results.
Outcomes:
When compared to watchful waiting and non-MRI methods, all strategies integrating prostate MRI increased QALYs and life-years in 60-year-old men. Annual MRI methods resulted in 16.19 QALYs, annual biopsy without an MRI resulted in 16.14 QALYs, and careful waiting resulted in 15.94 QALYs. Annual MRI with a PI-RADS score of at least 3 or 4 as the biopsy threshold and annual MRI with biopsy even after a negative MRI result had equal QALYs and the same unadjusted life expectancy: 23.05 years. A PI-RADS score of 4 or above, on the other hand, resulted in 42 percent fewer lifetime biopsies. Annual MRI with biopsy for lesions with PI-RADS scores of 4 or higher was the most cost-effective (incremental cost-effectiveness ratio, $67 221 per QALY) with a cost-effectiveness threshold of $100 000 per QALY. The results were influenced by age, treatment type, the probability of initial grade misclassification, and the quality-of-life effect of procedural problems.
Implication:
Active surveillance (AS) with biopsy decisions based on yearly MRI data lowers the frequency of biopsies while maintaining life expectancy and quality of life. Biopsy in lesions with a PI-RADS score of 4 or above is likely the most cost-effective AS approach for men under the age of 70 with low-risk prostate cancer.