Risk Calculator Strategy Before Magnetic Resonance Imaging Stratification for Biopsy-naïve Men with Suspicion for Prostate Cancer: A Cost-effectiveness Analysis

Abstract

Background and objectiveCurrent guidelines on prostate cancer (PCa) diagnosis recommend risk stratification before prostate biopsy, using either a risk calculator (RC) or magnetic resonance imaging (MRI). The aim of our study was to assess the effectiveness and cost effectiveness of an RC strategy and a direct MRI (dMRI) strategy. MethodsData for biopsy-naïve men suspected of having PCa on the basis of elevated prostate specific antigen (PSA) and/or abnormal digital rectal examination (DRE) were retrospectively collected from two large teaching hospitals. The RC and dMRI strategies were evaluated for PCa detection, effectiveness, and costs. The RC strategy used the Rotterdam prostate cancer risk calculator 3/4 and MRI for stratification, while the dMRI strategy directly used MRI findings. Clinically significant (cs)PCa was defined as a Gleason score ≥3 + 4. Key findings and limitationsIn total, 1458 men were included for analysis, of whom 944 were in the RC group and 514 were in the dMRI group. The RC strategy significantly reduced MRI use by 47.8% (52.2% vs 99.8%; p < 0.001) and reduced costs by 14.3% (€422.45 vs €492.77; p < 0.001) in comparison to the dMRI strategy. The number of patients who underwent prostate biopsy (36.5% vs. 40.9%; p = 0.11) and the csPCa detection rate (43.5% vs 45.2%; p = 0.69) were similar between the groups. The study is limited by its retrospective nature, so the findings should be interpreted with caution. Conclusions and clinical implicationsBoth the RC strategy and the dMRI strategy are viable options for PCa diagnosis, with the former significantly reducing MRI use and overall diagnostic costs per person. Therefore, the RC strategy might be preferred over dMRI, particularly in contexts aiming for sustainable health care practices that optimize resource allocation and cost effectiveness. Patient summaryWe compared two different approaches for men with a suspicion of prostate cancer. One uses a risk calculator to decide on whether to perform an MRI (magnetic resonance imaging) scan, and the other proceeds directly to MRI. In both cases, prostate biopsy is performed in cases with positive MRI findings. The number of patients who needed a biopsy and the cancer detection rate were similar for the two approaches.