Elsevier

European Urology

Volume 79, Issue 3, March 2021, Pages 413-418
European Urology

Prostate Cancer
Is Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography Imaging Cost-effective in Prostate Cancer: An Analysis Informed by the proPSMA Trial

https://doi.org/10.1016/j.eururo.2020.11.043Get rights and content

Abstract

Background

Before integrating prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) into routine care, it is important to assess if the benefits justify the differences in resource use.

Objective

To determine the cost-effectiveness of PSMA-PET/CT when compared with conventional imaging.

Design, setting, and participants

A cost-effectiveness analysis was developed using data from the proPSMA study. proPSMA included patients with high-risk prostate cancer assigned to conventional imaging or 68Ga-PSMA-11 PET/CT with planned health economics data collected. The cost-effectiveness analysis was conducted from an Australian societal perspective.

Intervention

68Ga-PSMA-11 PET/CT compared with conventional imaging (CT and bone scan).

Outcome measurements and statistical analysis

The primary outcome from proPSMA was diagnostic accuracy (nodal and distant metastases). This informed a decision tree analysis of the cost per accurate diagnosis.

Results and limitations

The estimated cost per scan for PSMA PET/CT was AUD$1203, which was less than the conventional imaging cost at AUD$1412. PSMA PET/CT was thus dominant, having both better accuracy and a lower cost. This resulted in a cost of AUD$959 saved per additional accurate detection of nodal disease, and AUD$1412 saved for additional accurate detection of distant metastases. The results were most sensitive to variations in the number of men scanned for each 68Ga-PSMA-11 production run. Subsequent research is required to assess the long-term costs and benefits of PSMA PET/CT-directed care.

Conclusions

PSMA PET/CT has lower direct comparative costs and greater accuracy compared to conventional imaging for initial staging of men with high-risk prostate cancer. This provides a compelling case for adopting PSMA PET/CT into clinical practice.

Patient summary

The proPSMA study demonstrated that prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) better detects disease that has spread beyond the prostate compared with conventional imaging. Our analysis shows that PSMA PET/CT is also less costly than conventional imaging for the detection of disease spread.

This research was presented at the European Association of Nuclear Medicine Scientific Meeting in October 2020.

Introduction

Radiolabelled small molecules targeting prostate-specific membrane antigen (PSMA) with positron emission tomography (PET) allow whole-body imaging for detection of prostate cancer spread [1]. The proPSMA randomised controlled trial (RCT) recently provided high-level evidence of superior diagnostic accuracy of PSMA PET/computed tomography (CT) compared with conventional imaging (CI; CT of the abdomen/pelvis and bone scanning) for detection of metastatic disease [2]. It showed that 68Ga-PSMA-11 PET/CT was more sensitive and specific at detecting pelvic lymph-node and distant metastatic disease in men with high-risk prostate cancer who are being considered for prostatectomy or radiotherapy.

Before integrating PSMA PET/CT into routine care, it is important to assess whether the additional benefits are justified by potential differences in the use of resources required for its implementation. This paper assesses the costs and outcomes (diagnostic accuracy) associated with the use of PSMA PET/CT compared with CI in staging men with high-risk prostate cancer using information collected as part of the proPSMA study.

Section snippets

Patients and methods

The design and conduct of the proPSMA study has been reported elsewhere [2]. In brief, proPSMA allocated high-risk prostate cancer patients being considered for prostatectomy or radiotherapy to first-line imaging with PSMA PET/CT or CI. The primary outcome was diagnostic accuracy using a predefined criterion encompassing histopathology, temporal changes in imaging, and biochemistry determined at the 6-month patient follow-up visit.

The population in the proPSMA study and subsequent economic

Results

proPSMA showed that PSMA PET/CT was more accurate in detecting metastatic and nodal disease than CI (Table 1). In addition, delivery of PSMA PET/CT required an average of 1.5 h per patient, compared with 5.5 h for CI (not including the time interval between the acquisition of bone scans on separate days for CT).

Nine sites provided information on the production of 68Ga-PSMA. Eight sites manufactured 68Ga-PSMA in their on-site hospital radiopharmacy, with an average yield of 615 MBq of 68Ga-PSMA

Discussion

This is the first economic evaluation to directly use data from a large RCT that demonstrated the superior accuracy of PSMA PET/CT in this setting. Our analysis indicates that PSMA PET/CT is dominant to CI in the short-term for staging men with high-risk disease, as it has greater diagnostic accuracy and is cheaper than CI.

Altering the detection of metastatic disease has implications for the downstream treatment of prostate cancer in terms of both health care service use and the impact on

Conclusions

PSMA PET/CT is dominant, with both lower direct comparative costs and greater accuracy when compared with CI for the detection of metastatic disease in men with high-risk prostate cancer. Combined with the other findings from proPSMA for patient management change, lower radiation exposure, and fewer equivocal findings, a compelling case can be made for adopting PSMA PET/CT.


Author contributions: Richard De Abreu Lourenco had full access to all the data in the study and takes responsibility for

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