28 148
(see the Supplementary material, section 9, for details,
including costs in euro). The line linking the cost-effective
strategies (in red) is the cost-effectiveness frontier, and its
slope corresponds to the incremental cost-effectiveness
ratio (ICER) of a strategy versus the next best (to its left); the
strategies on the frontier and their ICERs are shown in
Table 4. The strategy attaining the greatest expected health
outcomes was P4 2, and the next best strategy is M7
222. The ICER of P4 2 versus M7 222 was £30 084/QALY.
Next best toM7 222 is T7 223, and the ICER of M7 222 versus
T7 223 is £7076/QALY gained, making it a cost-effective
strategy in the UK setting. These results are consistent with
the cost-effectiveness acceptability frontier (Supplementa-
ry Fig. 1), in which M7 222 is the strategy most likely to be
cost effective for cost-effectiveness thresholds between
£7250 and £30 000/QALY.
3.2.
Sensitivity analysis
The cost-effective strategy changed from M7 222 to T7 222,
T9 222, or P4 2 in response to a reduction in the sensitivity
of MRI-targeted TRUSB and an increase in the sensitivity of
the MRI-targeted second TRUSB. The cost-effective strategy
changes to P4 2 if the sensitivity of the MRI-targeted second
TRUSB reduces, as this does not reduce its the CS cancer
detection rates. Increases in the cost of MPMRI coupled with
reductions in the cost of TRUSB result in strategies starting
with TRUSB becoming cost effective, while reductions in the
cost of TPMB favour strategies involving TPMB for all or a
large proportion of men. The cost-effective strategy
changed to less costly, less sensitive strategies (T7
223 and T6 222) if radical prostatectomy is less cost
effective, for example, due to reduced effectiveness, higher
HRQoL burden or greater costs. Conversely, the cost-
effective strategy changed to more sensitive strategies
(P4 2) in men incorrectly classified as no cancer has worse
health outcomes. For full results, see the Supplementary
material, section 9.
4.
Discussion
A diagnostic strategy consisting of MPMRI first and up to two
MRI-targeted TRUSB at the more sensitive definitions
(definition 2) and cut-offs is more likely to be cost effective
at cost-effectiveness thresholds at and below £30 000. For
MPMRI, this is lesion volume 0.2 cc and/or Gleason score
3 + 4 (likely benign or above); for TRUSB this is any Gleason
pattern 4 and/or cancer core length 4 mm. The most
clinically effective strategy is testing all men with TRUSB
at definition 2 and retesting men in whom CS cancer
was not detected with TPMB; however, this is not cost
effective at current cost-effectiveness thresholds and will
not be clinically feasible to deliver across the board in
any healthcare setting. These findings can directly inform
UK policy, but they can also be generalised to similar,
international, settings. The extent to which the cost
effectiveness results can be generalised to other jurisdictions
depends on the similarities of the population, outcomes,
health systems, and pricing.
Table 4
–
Cost-effectiveness results
Strategy
ICER/QALY
M1 115: MPMRI for all men de
fi
nition 1 cut-off 5; TRUSB in men suspicious of CS cancer de
fi
nition 1
Reference
M1 215: MPMRI for all men de
fi
nition 2 cut-off 5; TRUSB in men suspicious of CS cancer de
fi
nition 1
£3081
M3 215: MPMRI for all men de
fi
nition 2 cut-off 5; TRUSB in men with suspicion on CS cancer de
fi
nition 2; men with CNS at
fi
rst biopsy
receive second TRUSB de
fi
nition 2
£3630
M4 225: MPMRI for all men de
fi
nition 2 cut-off 5; TRUS-guided in men with suspicion of any cancer de
fi
nition 2; men with suspicion of CS
cancer at MPMRI and in whom CNS cancer was detected at the
fi
rst biopsy receive second TRUSB de
fi
nition 2
£3738
M7 225: MPMRI for all men de
fi
nition 2 cut-off 5; TRUSB de
fi
nition 2 in men with suspicion of CS cancer; rebiopsy with TRUSB de
fi
nition
2 in those in whom CS cancer was not detected
£3867
M3 224: MPMRI for all men de
fi
nition 2 cut-off 4; TRUSB de
fi
nition 2 in men with suspicion on CS cancer; men with CNS at
fi
rst biopsy
receive second TRUSB de
fi
nition 2
£3921
M4 224: MPMRI for all men de
fi
nition 2 cut-off 4; TRUSB de
fi
nition 2 in men with suspicion of any cancer; men with suspicion of CS
cancer at MPMRI and in whom CNS cancer was detected at the
fi
rst biopsy receive second TRUSB de
fi
nition 2
£4031
M7 224: MPMRI for all men de
fi
nition 2 cut-off 4; TRUSB de
fi
nition 2 in men with suspicion of CS cancer; rebiopsy with TRUSB de
fi
nition
2 in those in whom CS cancer was not detected but MPMRI had suspicion of CS cancer
£4250
T6 223: TRUSB de
fi
nition 2 for all men; men classi
fi
ed to have CNS receive an MRI de
fi
nition 2 cut-off 3; men with suspicion of CS cancer
receive a second TRUSB de
fi
nition 2
£4393
T6 222: TRUSB de
fi
nition 2 for all men; men classi
fi
ed to have CNS receive an MRI de
fi
nition 2 cut-off 2; men with suspicion of CS cancer
receive a second TRUSB de
fi
nition 2
£4633
M7 223: MPMRI for all men de
fi
nition 2 cut-off 3; TRUSB de
fi
nition 2 in men with suspicion of CS cancer; rebiopsy with TRUSB de
fi
nition
2 in those in whom CS cancer was not detected
£5501
T7 223: TRUSB de
fi
nition 2 for all men; men classi
fi
ed to have NC or CNS receive an MPMRI de
fi
nition 2 cut-off 3; men with suspicion of CS
cancer receive a second TRUSB de
fi
nition 2
£5778
M7 222: MPMRI de
fi
nition 2 cut-off 2 for all men; TRUSB de
fi
nition 2 in men with suspicion of CS cancer; rebiopsy with TRUSB de
fi
nition
2 in those in whom CS cancer was not detected but MPMRI had suspicion of CS cancer
£7076
P4 2: TRUSB de
fi
nition 2 in all men and TPMB in men in whom CS cancer was not detected
£30 084
CS = clinically signi
fi
cant; ICER = incremental cost-effectiveness ratio; MPMRI = multiparametric magnetic resonance imaging; QALY = quality-adjusted life year.
TPMB = template prostate mapping biopsy. TRUSB = transrectal ultrasound-guided biopsy.
The strategies in the cost-effectiveness frontier are shown, together with their ICERs versus the next best strategy. TRUSB after an MPMRI is assumed to be an
MRI-targeted TRUSB, as information on the location of the lesion is provided by the MPMRI.
E U R O P E A N U R O L O GY 7 3 ( 2 0 18 ) 2 3
–
3 0
28