What’s more important: saving men’s lives or saving healthcare dollars? Obviously, saving life is the top priority. But, if the two values could be combined at a single stroke, who wouldn’t jump at it?

The way to achieve this integration is spelled out in a Nov. 2022 online JAMA Oncology article. In “Cost effectiveness of Prostate Cancer Screening Using Magnetic Resonance Imaging or Standard Biopsy Based on the STHLM3-MRI Study,” Swedish researchers analyze the life and financial costs of the standard prostate cancer (PCa) screening/diagnostic pathway vs. that of an alternative pathway that integrates MRI into PSA screening.^[i] Let’s take a closer look at these two pathways.

Standard pathway

When the PSA blood test emerged during the 1990s, it quickly became the screening standard for PCa. However, controversy over its use arose from the fact that for enormous numbers of men, the standard next step was a referral for a painful (and often inaccurate) TRUS biopsy, with subsequent whole-gland treatment for those whose biopsy was positive for PCa. Not only was it expensive to dole out surgeries and radiation therapies, further medical expenses were added due to managing chronic treatment side effects. At the same time, flawed studies seemed to prove that the blood test did not save enough lives to justify the loss of quality of life for men left with urinary, sexual and bowel impairments, so broad PSA screening was discouraged.

The PSA + MRI pathway

Compare the standard pathway with one proposed by the article’s authors. Recent studies have corrected the incorrect information that PSA did not save lives; on the contrary, the most recent studies now show that when PSA screening drops off, within a few years there are more men being diagnosed with later stage PCa, even incurable metastatic disease. It is thus crucial for men to participate in annual PSA screening.

How, then, to avoid the earlier problems of over-biopsy and over-treatment? The Swedish authors proposed adding MRI after PSA but before biopsy for men whose blood test is abnormally high. This avoids over-detection. Then, if MRI reveals a suspicious lesion, add a targeted biopsy into the lesion plus a standard biopsy to sample other parts of the gland; if a PCa diagnosis is made, a treatment plan (including Active Surveillance and focal treatment options as well as radical treatment) can thus be tailored to the individual’s disease. This, in turn, avoids over-treatment.

How the Swedish study results reveal the new pathway

The merits of the PSA + MRI pathway is confirmed by the Swedish population-based described in the JAMA Oncology article. It involved men ages 55-69 who had no diagnosis of prostate cancer. Participants were randomized into 3 groups: a) no screening, b) screening + standard TRUS biopsy, and c) screening + MRI before biopsy. In group c, if MRI revealed a suspicious lesion with a PI-RADS value between 3-5, the patient would then undergo a targeted biopsy into the lesion plus a standard biopsy.

The research team then used data from the Stockholm PSA and Biopsy Register to simulate life histories of the individuals, including PCa testing, onset of cancer, progression, diagnosis, disease management and deaths. Finally, they used the life history model to project the outcomes and costs of all three strategies (including no screening).

Here are the key results of the study:

• Compared with no screening, both screening pathways were projected to reduce PCa-related deaths by 6-9%. (Yes, screening saves lives.)
• Compared to the standard pathway, the PSA + MRI pathway “reduced the number of both lifetime biopsies and overdiagnosis by approximately 50%.” (Yes, MRI avoids overdiagnosis.)
• Taking the total PCa diagnosis/treatment and quality of life costs into account, the researchers calculate the incremental savings of the PSA + MRI pathway over the standard pathway at U.S. $53,736 per patient. (Yes, MRI treatment planning reduces overtreatment and its associated price tag.)
• Thus, PSA + MRI “had a high probability of being cost effective.”

The authors conclude with a suggestion that MRI-based screening be considered as the new standard in Sweden. In response, we would add this question: Given that early detection saves lives, and the addition of MRI into PSA screening can save tens of thousands of dollars over the lifetime of each patient, why wouldn’t we universally adopt this screening pathway?

Kudos to the study authors for making good economic sense. More importantly, they have demonstrated the ethical value of embracing the relatively small coast of an imaging session as a way to save bigger medical dollars, and most of all, preserving the longevity and lifestyle of untold thousands of men.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Hao S, Discacciati A, Eklund M, et al. Cost-effectiveness of Prostate Cancer Screening Using Magnetic Resonance
Imaging or Standard Biopsy Based on the STHLM3-MRI Study. JAMA Oncol. Published online November 10, 2022.