• Roman Gulati, Boshen Jiao, Ra'ad Al-Faouri, Vidit Sharma, Sumedh Kaul, Aaron Fleishman, Kevin Wymer, Stephen A Boorjian, Aria F Olumi, Ruth Etzioni, and Boris Gershman.
• Fred Hutchinson Cancer Center, Seattle, Washington (R.G., R.E.).
• Ann. Intern. Med. 2024 Jul 1; 177 (7): 871881871-881.

BackgroundContemporary prostate cancer (PCa) screening uses first-line prostate-specific antigen (PSA) testing, possibly followed by multiparametric magnetic resonance imaging (mpMRI) for men with elevated PSA levels. First-line biparametric MRI (bpMRI) screening has been proposed as an alternative.ObjectiveTo evaluate the comparative effectiveness and cost-effectiveness of first-line bpMRI versus PSA-based screening.DesignDecision analysis using a microsimulation model.Data SourcesSurveillance, Epidemiology, and End Results database; randomized trials.Target PopulationU.S. men aged 55 years with no prior screening or PCa diagnosis.Time HorizonLifetime.PerspectiveU.S. health care system.InterventionBiennial screening to age 69 years using first-line PSA testing (test-positive threshold, 4 µg/L) with or without second-line mpMRI or first-line bpMRI (test-positive threshold, PI-RADS [Prostate Imaging Reporting and Data System] 3 to 5 or 4 to 5), followed by biopsy guided by MRI or MRI plus transrectal ultrasonography.Outcome MeasuresScreening tests, biopsies, diagnoses, overdiagnoses, treatments, PCa deaths, quality-adjusted and unadjusted life-years saved, and costs.Results Of Base Case AnalysisFor 1000 men, first-line bpMRI versus first-line PSA testing prevented 2 to 3 PCa deaths and added 10 to 30 life-years (4 to 11 days per person) but increased the number of biopsies by 1506 to 4174 and the number of overdiagnoses by 38 to 124 depending on the biopsy imaging scheme. At conventional cost-effectiveness thresholds, first-line PSA testing with mpMRI followed by either biopsy approach for PI-RADS 4 to 5 produced the greatest net monetary benefits.Results Of Sensitivity AnalysisFirst-line PSA testing remained more cost-effective even if bpMRI was free, all men with low-risk PCa underwent surveillance, or screening was quadrennial.LimitationPerformance of first-line bpMRI was based on second-line mpMRI data.ConclusionDecision analysis suggests that comparative effectiveness and cost-effectiveness of PCa screening are driven by false-positive results and overdiagnoses, favoring first-line PSA testing with mpMRI over first-line bpMRI.Primary Funding SourceNational Cancer Institute.

35 keywords...

hide…