Prostate CancerIs Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography Imaging Cost-effective in Prostate Cancer: An Analysis Informed by the proPSMA Trial
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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2023, European UrologyCitation Excerpt :In another prospective multicentre trial of patients with intermediate- and high-risk prostate cancer, staging by PSMA PET and conventional imaging identified suspected nodal and bone or visceral metastases in 25% and 6% of patients, respectively, and staging by PSMA PET led to a change in planned management in 23 of 108 patients (21%) [10]. These findings and those from other important studies have led to the regulatory approval of PSMA PET [9–15]. It has been suggested by some experts to refine the tumour-node-metastasis (TNM) staging system by including a notation for PSMA PET–positive lesions not seen on conventional imaging [16].