Slowly but perhaps inexorably we seem to be seeing increasing scientific and clinical justification for the argument that all men thought to be at risk for a diagnosis of prostate cancer should be given an MRI scan prior to any form of prostate biopsy. The question of whether such a diagnostic strategy is cost-efficient has received much less attention, but will be crucial to the acceptance of such a diagnostic strategy here in the USA — as will access to high quality MRI scans and a large enough pool of skilled uroradiologists who can “read” such MRI scans with a high level of consistency and accuracy.
The latest addition to the literature documenting the clinical and diagnostic value of this strategy is a paper by Mehralivand et al. in JAMA Oncology. This multi-center research group has shown that the use of a high-quality MRI scan prior to biopsy could be used to reduce the rate of biopsy by 18 percent in a cohort of 400 patients. They then were able to validate this result in a different cohort of 251 patients.
Basically, the research team was able to show that, based on the assumption that any man with a Gleason score of 3 + 4 = 7 had clinically significant prostate cancer, their MRI model — in which all patients received an MRI scan and then an MRI/TRUS fusion-guided biopsy that included targeted biopsies of suspicious areas of the prostate and a systematic 12-core biopsy — demonstrated
- A lower false-positive rate than the baseline model (46 vs 92 percent)
- A small reduction in the true-positive rate (89 vs 99 percent)
- No increase in the number of patients with missed, clinically significant prostate cancers
A summary report on the paper by Mehralivand et al. can be found on the PracticeUpdate web site.
However, the question of cost-efficiency is going to be crucial.
When a man is diagnosed with prostate cancer today, it is commonly done only by the use of a 12-core, systematic, TRUS-guided biopsy at a suite in a urologist’s office and review of the biopsy cores by a suitably qualified pathology laboratory. The exact cost for the biopsy and the pathology review varies (significantly) across the country and so it is impossible to provide an “exact” average cost.
In contrast, when a man is given a specialized prostate MRI, and the MRI scan is reviewed by a suitably qualified uroradiologist, we are now dealing with a different set of costs overall:
- The costs of the MRI for all patients
- The costs associated with uroradiological review of the MRI for all patients
- The costs for the MRI/TRUS fusion-guided biopsy (inclusive of the 12-core, systematic biopsy, and any targeted biopsies of visible areas of risk) for the 82 percent of patients who still need a biopsy
- The costs of the pathological review of the biopsy specimens
It seems highly unlikely that this four-part cost is lower than the two-part cost associated with a simple TRUS-guided, 12-core biopsy.
So from a cost-efficiency perspective, the question becomes: What costs have been saved if we do the MRI and the MRI/TRUS fusion-guided biopsy? And these cost savings include the following:
- The costs of the MRI/TRUS fusion-guided biopsy for the 18 percent of patients who didn’t need that biopsy based on their MRI result
- The costs saved because 18 percent of patients never had a biopsy and therefore were never at risk for the short-term complications and side effects of prostate biopsy (most particularly, prostate infections and, more seriously, hospitalizations as a consequence of more severe forms of prostate infection)
- The costs associated with unnecessary, invasive treatment of men with low-risk forms of prostate cancer that didn’t ever get diagnosed.
For the payor community to be willing to embrace the idea of standard MRIs prior to all prostate biopsies the amount of money saved is going to need to be close to the additional costs associated with the more sophisticated, four-part as opposed to two-part diagnostic process.
It would be interesting to know whether a knowledgeable and specialized healthcare economist could assess these costs with a relatively high degree of accuracy.
Filed under: Diagnosis | Tagged: biopsy, cost, efficiency, MRI, standard |
THE "NEW" PROSTATE CANCER INFOLINK 
MRI is a cheap test. … You can negotiate to have it done for a few hundred dollars, if you pay cash. The problem is that this is basically kept hidden from the public. The solution is for MRI facilities to post their self-pay prices for MRIs and to eliminate price fixing.
Dear Doug:
Respectfully, most people simply don’t have “a few hundred dollars” available in cash. That may be a “cheap test” for you, but not for the majority of people living in America.
OK, but if you proceed to biopsy and/or prostate cancer treatment, your co-pays or other out of pocket costs will likely be a few thousand … maybe more. Better to pay a few hundred up front and avoid unnecessary biopsy and/or treatment for low volume Gleason 6, IMO.
These days, it’s insane to have a biopsy without an MRI. … You need some idea of where the cancer is.
I think that most people, when confronting a possible cancer diagnosis, can come up with a few hundred, if their insurance won’t cover it.
Multiparametric MRI (mpMRI) cost issues – the contrast question
It is not clear from the abstract whether the MRI was the mpMRI version, which provides much more data than a simple MRI, but is definitely not cheap, at least currently in the US.
Dr. Mark Emberton, based in London and widely known for his expertise in focal therapy, is exploring whether the contrast element of an mpMRI can be eliminated. It is the major cost contributor, and it appears that some of its value, perhaps much of its value, overlaps the other mpMRI parameters. He visualized mpMRIs being done in supermarkets if the contrast aspect could be eliminated. He gave a very nice talk that focused on the use and value of mpMRI for prostate cancer at the 2016 Conference on Prostate Cancer in Los Angeles (as well as two Q&A sessions).
Dear Jim:
I like Mark Emberton a lot, but the day we start doing MRIs in supermarkets will be the guarantee that we are providing bad medical care. Who do you think will be reading all those MRI scans? Even trained and experienced radiologists have a hard time doing that with consistency and accuracy.
Dear Doug:
As I wrote elsewhere a day or so ago: “We should remember that (as of November 2015) a study by the Pew Charitable Trusts reported that one in three American families have no savings at all. And (in December 2015), another study found that 56.3 percent of Americans had < $1,000 in their checking and savings accounts combined."
Respectfully, I don't think that most of those people "can come up with a few hundred" for much of anything. And that's if they even have insurance.
“Basically, the research team was able to show that, based on the assumption that any man with a Gleason score of 3 + 4 = 7 …”
Forgive me for being dense but how would you know you had a Gleason score of any measure without having first had a biopsy?
Dear J-P:
You seem to be missing the point. What this study is claiming to have shown is that a high-quality MRI, when read by an appropriately trained uroradiologist, can accurately discriminate between men with potentially clinically significant disease and potentially clinically insignificant disease without the need for a biopsy at all.
Since the clinician knows each patient’s PSA level and clinical stage without the need for a biopsy or any type of scan, the implication is therefore that the MRI can discriminate between tumors that will have a Gleason score of 6 or lower and a Gleason score of 3 + 4 = 7 or higher.