Originally published 11/4/2020
What happens to healthcare spending when mpMRI is included as a pre-biopsy step in the diagnostic pathway for prostate cancer (PCa)?
This update summarizes a subsequent analysis from our forward looking British colleagues, including Mark Emberton.
Their projected savings help override shortsighted urologic naysayers who point to the cost of an individual prostate MRI and overlook the long view: big economic savings over time from avoiding unnecessary biopsies and their downstream effects.
They modeled a hypothetical cohort of 4.48 million men ages 55-69, following this cohort out to 90 years of age for a long-term calculation.
They note, “The MRI-first risk-stratified screening strategies were more cost-effective than MRI-first age-based screening and were associated with less overdiagnosis and a comparable number of prevented deaths from prostate cancer.”[i]
Here are the numbers: MRI-first risk stratified screening resulted in up to 72.6% less overdiagnosis, and up to 53.5% fewer biopsies.
Overall, the benefit-harm profile and cost-effectiveness were most improved with the MRI-first risk-stratified screening based on age and genomic profiling. It’s an elegant solution to overspending on the conventional biopsy-first strategy.
First, for full disclosure, the exciting study I’m about to describe is from Australia, not the U.S.
Second, who doesn’t love to save millions of dollars? Multiparametric MRI offers huge savings in healthcare spending by ruling out need for a prostate biopsy—not to mention saving thousands of men the anxiety of being rushed into something unpleasant that may be totally unnecessary.
Greater healthcare economy is exactly what a team of five Australian research analysts prove in an October, 2020 published paper.[ii] It opens with a statement that I have been using like a mantra throughout my past 6 years of blogs: “Introduction of multiparametric MRI of the prostate (mpMRIp) has transformed diagnosis of prostate cancer.”
I don’t need to belabor the clinical benefits of mpMRI for both doctors and patients, since I’ve written much about that. Let’s focus instead on the economic advantage of incorporating mpMRI into the prostate cancer (PCa) diagnostic pathway.
The authors of the paper have the advantage of a clear timeline for tracking the fiscal impact of prostate mpMRI because it simply wasn’t available in Australia prior to 2012. Then, from 2012-2018, it became available through private funding (no government rebate). Finally, starting in 2018, payment became available through the Australian Medicare system (government rebate). Patient case records were available via a publicly available database of de-identified data from 2007 onward, so the impact of mpMRI before biopsy could be tracked and analyzed.
Effect of mpMRI on biopsy rates
The authors report that, starting with the 2012 availability of mpMRI, the number of biopsies declined at an average rate of 414 per month. However, during the same period (2012 – 2019) the number of PSA tests also fell, possibly due to the influence of the 2012 U.S. Preventive Services Task Force’s downgrading of the test, which likewise caused a significant drop in screening in the U.S. In any case, the authors corrected for this in their ultimate analysis.
For the financial analysis, the team calculated the reduction in total biopsy costs once use of mpMRI became integrated in the Australian PCa diagnostic pathway. In Australia, prostate biopsies are done in a hospital operating room, under anesthesia. Total costs include not just the biopsy itself, but hospital readmissions due to complications, particularly infection. Thus, the team analyzed the reduction in real costs due to fewer biopsies during the study period, plus the projected savings due to fewer hospital readmissions (average stay 4 days for post-biopsy infections).
The result is an enormous saving of healthcare spending. As stated in the paper, “Availability of mpMRIp in Australia has correlated with a significant reduction in prostate biopsy rates, with an estimated annual saving of $13.2 + $9.6 million.” (Currently $1 U.S. = $1.40 AUS) The authors note that government reimbursement for mpMRI costs is a way to save on biopsy spending, noting that this has the “potential to improve health equity and save on health expenditure.”
But wait, there’s more! This isn’t just true for Australia or for prostate biopsies. It also applies to our own PCa diagnosis/treatment pathway, especially given the increasing number of high-risk PCa cases found during initial biopsy (experts believe this is happening because of the drop in PSA screening). A compelling report of a not-for-profit study of Massachusetts healthcare spending suggests that the state could save “….more than $200 million annually by using MRIs to diagnose aggressive prostate cancer.”
Here in the U.S., we are fortunate to have ever-growing access to 3T mpMRI, so there’s little excuse for ignoring the need for annual PSA tests. A suspicious PSA result should lead straight to mpMRI, not a rush to biopsy. We can give a shout-out to the analysts from “Down Under” for providing clear evidence that this approach is well worth the money it saves.
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] Callender T, Emberton M, Morris S, Pharoah PDP, Pashayan N. Benefit, Harm, and Cost-effectiveness Associated With Magnetic Resonance Imaging Before Biopsy in Age-based and Risk-stratified Screening for Prostate Cancer. JAMA Netw Open. 2021;4(3):e2037657.
[ii] Whish-Wilson T, Costello D, Finch S, Sutherland T, Wong L. Funding of prostate magnetic resonance imaging leads to fewer biopsies and potential savings to health systems in the management of prostate cancer. BJU Int. 2020 Oct 6. doi: 10.1111/bju.15231. Online ahead of print.