EURURO Vol. 73 No. 1

31 148

Platinum Priority – Editorial
Referring to the article published on pp. 23–30 of this issue
The “PROMIS” of Magnetic Resonance Imaging Cost Effectiveness
in Prostate Cancer Diagnosis?
Jochen Walz
Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France
Since multiparametric magnetic resonance imaging
(mpMRI) was introduced into diagnostic pathways for
prostate cancer, there has been ongoing controversy about
the cost effectiveness of such pathways. mpMRI is currently
recommended before a repeat biopsy, but some authors also
favor use of mpMRI before the first biopsy . mpMRI is
without doubt a rather expensive test that is time-intensive
and resource-consuming. These issues stand in the context
of the epidemiological characteristics of prostate cancer, the
most frequent male cancer in the Western world, with
further increases in incidence expected. Together these
features represent a major challenge for health care systems
if mpMRI is to be used systematically before any biopsy. For
these reasons, systematic use of mpMRI in the diagnosis of
prostate cancer needs to be carefully evaluated.
In this issue of European Urology, Faria and colleagues
describe a cost-effectiveness analysis based on PROMIS
a trial among[1_TD$DIFF] 576 biopsy-naïve men in which 1.5-T mpMRI
was followed by a 5-mm transperineal template mapping
biopsy and then a standard transrectal 12-core biopsy to
evaluate the diagnostic accuracy of mpMRI before first
biopsy. From their analysis, Faria and colleagues conclude
that the most cost-effective use of mpMRI is scenario M7
222, involving mpMRI before a first biopsy followed by up to
two mpMRI –targeted biopsies if negative, which has
sensitivity of 0.95 (95% confidence interval [CI] 0.92–
0.98), a testing cost of £807 per man (95% CI £777–£833),
and an incremental cost-effectiveness ratio (ICER) of £7076
per quality-adjusted life year (QALY) gained relative to an
approach using systematic biopsy first.
There are several points that should be addressed. First,
when looking at the 383 different possible scenarios, the
combination of a systematic transrectal biopsy followed by
an mpMRI-guided biopsy (scenario T7 222) resulted in
sensitivity of 0.91 (95% CI 0.86 –0.94) and a testing cost of
£709 per man (95% CI £688–£730), which is significantly
less expensive but not significantly less effective. When
leaving out other outcomes such as ICER/QALY, which
largely depend on arbitrary thresholds and assumptions,
this provides evidence that the current recommendation of
a systematic biopsy first, followed by an mpMRI-guided
approach might be a valid option. Second, the data are based
on the PROMIS trial, which has several limitations. For the
current analysis the most relevant limitation of PROMIS is
that no MRI-guided or MRI-targeted biopsies were per-
formed. All the results in PROMIS are presented assuming
that targeted biopsies would achieve similar diagnostic
accuracy as the transperineal template biopsy . It is clear
that this assumption is not realistic. The true performance
of the mpMRI pathway will be lower . The PROMIS
investigators recognized that they cannot accurately assess
the clinical utility of an MRI-targeted biopsy approach, but
such an approach is the cornerstone of an MRI pathway and
a pivotal aspect for realistic cost-effectiveness analysis. The
sensitivity analysis in the current publication demonstrates
that if the sensitivity of MRI is reduced (which will occur in
real life), the strategy of systematic biopsy first followed by
an mpMRI-guided approach second (scenario T7 222)
becomes the most cost effective. This observation needs
to be taken into account when drawing conclusions from
the analysis. Third, there are several flaws associated with
the use of mpMRI that depend largely on quality and quality
assurance. The mpMRI scans in PROMIS were carried out
after centralized and repeated training of radiologists and
ava ilable at
journal homepage:
DOI of original article: .
* Department of Urology, Institut Paoli-Calmettes Cancer Centre, 232 Boulevard Ste. Marguerite, 13009 Marseille, France. Tel. +33 49 1223532; Fax:
+33 49 1223613.
E-mail address: .
0302-2838/© 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.