Cost-Effectiveness Analysis and Microsimulation of Serial Multiparametric Magnetic Resonance Imaging in Active Surveillance of Localized Prostate Cancer

No AccessJournal of UrologyAdult Urology1 Jul 2022Cost-Effectiveness Analysis and Microsimulation of Serial Multiparametric Magnetic Resonance Imaging in Active Surveillance of Localized Prostate Cancer Christopher J. Magnani, Tina Hernandez-Boussard, Laurence C. Baker, Jeremy D. Goldhaber-Fiebert, and James D. Brooks Christopher J. MagnaniChristopher J. Magnani https://orcid.org/0000-0001-5757-9832 School of Medicine, Stanford University, Stanford, California Stanford Health Policy, Centers for Health Policy/Primary Care and Outcomes Research, Stanford University, Stanford, California Division of Urological Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts More articles by this author , Tina Hernandez-BoussardTina Hernandez-Boussard Department of Medicine, School of Medicine, Stanford University, Stanford, California More articles by this author , Laurence C. BakerLaurence C. Baker Stanford Health Policy, Centers for Health Policy/Primary Care and Outcomes Research, Stanford University, Stanford, California Department of Medicine, School of Medicine, Stanford University, Stanford, California More articles by this author , Jeremy D. Goldhaber-FiebertJeremy D. Goldhaber-Fiebert Stanford Health Policy, Centers for Health Policy/Primary Care and Outcomes Research, Stanford University, Stanford, California Department of Medicine, School of Medicine, Stanford University, Stanford, California Co-senior authors. More articles by this author , and James D. BrooksJames D. Brooks †Correspondence: Department of Urology, Stanford University, 300 Pasteur Dr., S-287, Stanford, California 94305 telephone: 650-725-5746; FAX: 650-498-5346; E-mail Address: [email protected] Department of Urology, Stanford University, Stanford, California Co-senior authors. More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002490AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: Many localized prostate cancers will follow an indolent course. Management has shifted toward 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 and costs adjusted to 2020 US$ were used to calculate expected net monetary benefit at $50,000/quality-adjusted life-year and incremental cost-effectiveness ratios. 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 net monetary benefit (incremental cost-effectiveness ratio $44,576). Biopsy after both positive and negative imaging (MRI pathway) and TRUS biopsy 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. References 1. : Prevalence of incidental prostate cancer: a systematic review of autopsy studies. Int J Cancer 2015; 137: 1749. Google Scholar 2. : National trends in the management of low and intermediate risk prostate cancer in the United States. J Urol 2015; 193: 95. Link, Google Scholar 3. : Active surveillance for prostate cancer: a narrative review of clinical guidelines. Nat Rev Urol 2016; 13: 151. Google Scholar 4. : Comparative analysis of biopsy upgrading in four prostate cancer active surveillance cohorts. Ann Intern Med 2018; 168: 1. 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Google Scholar 22. : Long-term follow-up of a large active surveillance cohort of patients with prostate cancer. J Clin Oncol 2015; 33: 272. Google Scholar 23. Tufts Medical Center: Cost-Effectiveness Analysis (CEA) Registry. 2021. Available at https://cevr.tuftsmedicalcenter.org/databases/cea-registry. Accessed February 11, 2021. Google Scholar 24. : Linear regression metamodeling as a tool to summarize and present simulation model results. Med Decis Making 2013; 33: 880. Google Scholar 25. : Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA 2009; 302: 1557. Google Scholar 26. : Economic analysis of prostate-specific antigen screening and selective treatment strategies. JAMA Oncol 2016; 2: 890. Google Scholar 27. : Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst 2011; 103: 117. Google Scholar 28. : Quality-of-life effects of prostate-specific antigen screening. N Engl J Med 2012; 367: 595. Google Scholar 29. : Utilities for prostate cancer health states in men aged 60 and older. Med Care 2005; 43: 347. Google Scholar Support: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number R01CA183962. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. C.J. Magnani was supported by the Stanford University MedScholars program. Conflict of Interest: The authors attest that they have no conflicts of interest. Ethics Statement: This study was exempted by the Stanford University Institutional Review Board (IRB) as only publicly available published sources were used in the modeling analysis. Author Contributions: C.J. Magnani had full access to all data and analytical code in the study and takes responsibility for the integrity and accuracy of the work. He attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. He affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. Conception and design: Magnani, Hernandez-Boussard, Baker, Goldhaber-Fiebert, Brooks. Acquisition of data: Magnani, Brooks. Analysis & interpretation of data: Magnani, Hernandez-Boussard, Baker, Goldhaber-Fiebert, Brooks. Drafting of the manuscript: Magnani. Critical manuscript revision for important intellectual content: Magnani, Hernandez-Boussard, Baker, Goldhaber-Fiebert, Brooks. Statistical analysis: Magnani. Obtaining funding: Hernandez-Boussard. Administrative, technical, or material support: Hernandez-Boussard, Goldhaber-Fiebert. Study supervision: Goldhaber-Fiebert, Brooks. Other: None. Data Availability: Data used in analysis and modeling were derived from publicly available published sources with references provided. Submission History: Preliminary work from this study was presented at the Annual Meeting of the Society of Medical Decision Making in October of 2021 where it was recognized as a finalist in the Lusted Student Prize Competition. Editor's Note: This article is the first of 5 published in this issue for which Category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 226 and 227. © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited bySiemens D (2022) This Month in Adult UrologyJournal of Urology, VOL. 208, NO. 1, (1-2), Online publication date: 1-Jul-2022. Volume 208Issue 1July 2022Page: 80-89Supplementary Materials PEER REVIEW REPORT Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.Keywordsmultiparametric magnetic resonance imagingcost-benefit analysiswatchful waitingprostatic neoplasmsSome of the computing and large calculations for this project were performed using the Sherlock cluster, and we thank Stanford University and the Stanford Research Computing Center for providing these computational resources and essential support.MetricsAuthor Information Christopher J. Magnani School of Medicine, Stanford University, Stanford, California Stanford Health Policy, Centers for Health Policy/Primary Care and Outcomes Research, Stanford University, Stanford, California Division of Urological Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts More articles by this author Tina Hernandez-Boussard Department of Medicine, School of Medicine, Stanford University, Stanford, California More articles by this author Laurence C. Baker Stanford Health Policy, Centers for Health Policy/Primary Care and Outcomes Research, Stanford University, Stanford, California Department of Medicine, School of Medicine, Stanford University, Stanford, California More articles by this author Jeremy D. Goldhaber-Fiebert Stanford Health Policy, Centers for Health Policy/Primary Care and Outcomes Research, Stanford University, Stanford, California Department of Medicine, School of Medicine, Stanford University, Stanford, California Co-senior authors. More articles by this author James D. Brooks Department of Urology, Stanford University, Stanford, California †Correspondence: Department of Urology, Stanford University, 300 Pasteur Dr., S-287, Stanford, California 94305 telephone: 650-725-5746; FAX: 650-498-5346; E-mail Address: [email protected] Co-senior authors. More articles by this author Expand All Support: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number R01CA183962. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. C.J. Magnani was supported by the Stanford University MedScholars program. Conflict of Interest: The authors attest that they have no conflicts of interest. Ethics Statement: This study was exempted by the Stanford University Institutional Review Board (IRB) as only publicly available published sources were used in the modeling analysis. Author Contributions: C.J. Magnani had full access to all data and analytical code in the study and takes responsibility for the integrity and accuracy of the work. He attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. He affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. Conception and design: Magnani, Hernandez-Boussard, Baker, Goldhaber-Fiebert, Brooks. Acquisition of data: Magnani, Brooks. Analysis & interpretation of data: Magnani, Hernandez-Boussard, Baker, Goldhaber-Fiebert, Brooks. Drafting of the manuscript: Magnani. Critical manuscript revision for important intellectual content: Magnani, Hernandez-Boussard, Baker, Goldhaber-Fiebert, Brooks. Statistical analysis: Magnani. Obtaining funding: Hernandez-Boussard. Administrative, technical, or material support: Hernandez-Boussard, Goldhaber-Fiebert. Study supervision: Goldhaber-Fiebert, Brooks. Other: None. Data Availability: Data used in analysis and modeling were derived from publicly available published sources with references provided. Submission History: Preliminary work from this study was presented at the Annual Meeting of the Society of Medical Decision Making in October of 2021 where it was recognized as a finalist in the Lusted Student Prize Competition. Editor's Note: This article is the first of 5 published in this issue for which Category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 226 and 227. Advertisement PDF downloadLoading ...