When it comes to spending money, you have choices. According to wealthfit.com, “Whether you spend 10 seconds or 10 days weighing a decision, each one comes with strings attached. With each option you choose, you’re saying ‘no’ to a different option. The value of what you do not select is called your opportunity cost. You can think of it as the value of what could have been.”

Most of us don’t think of PSA screening for prostate cancer in terms of healthcare value. You have a PSA blood test because of personal value: it could save your life! And yet, broad PSA screening has led to untold costs, such as:

• Unnecessary biopsies, with their attendant risks of more cost down the line due to side effects
• Unnecessary and expensive radical treatments such as robotic surgery or radiation therapies
• More costs for treating urinary incontinence or sexual dysfunction as a result of radical therapy

Then there’s the price tag that comes with lower quality of life, the psychological and social damage experienced by men struggling with the aftereffects of treatment.

How many healthcare dollars have been spent because the prostate cancer (PCa) diagnostic pathway has consisted of a) suspicious PSA or DRE, leading to b) inaccurate ultrasound-guided systematic biopsies with 12+ needles, leading to c) whole gland treatments for untold numbers of cases with insignificant PCa that may never have required treatment, leading to d) consequent remedial treatments and personal treatment regret? These are seemingly incalculable healthcare costs.

Is there a better, more cost-effective diagnostic pathway that also preserves greater dignity and quality of life? If so, how does one go about calculating the costs and benefits?

New study reveals savings with risk-stratified use of MRI before biopsy

A rather brilliant British study published online (Callender, et al., March 2021) examines the opportunity costs associated with the traditional diagnostic pathway for PCa, and offers a more cost-effective way to improve benefits while reducing harms. Simply put, do a multiparametric MRI (mpMRI) BEFORE biopsy.

The authors note that a body of published research already shows that an mpMRI before biopsy saves roughly a third of men from biopsy. However, they point out that the actual gains of MRI-first programs have not been calculated. There are different approaches to MRI-first screening, so it’s important to know which approach is the most cost-effective while increasing the proportion of benefits over harms.

To perform these calculations, they created a decision analytical model using a hypothetical population of 4.48 million men, ages 55-69, while following the costs out to 90 years of age for all men. They examined two scenario models in which they ran the costs:

1. Age-based screening (PSA tests every four years between ages 55-69)
2. Risk-stratified screening (using age and genomic/family history risk factors)

They applied their analytic model to biopsy-first detection/diagnosis, and both models of MRI-first (before biopsy) detection/diagnosis to rule out need for biopsy and overtreatment.

An investment in MRI screening brings bigger economies down the line

The research team acknowledged the initial higher price of adding mpMRI to a screening program, but hypothesized more benefits while sparing opportunity costs linked with the biopsy-first pathway:

Offering MRI before biopsy in a population-based screening program for prostate cancer would entail additional cost. However, this cost may be offset by fewer biopsies and a reduction in the number of men diagnosed with prostate cancer, largely by mitigating [lessening] overdiagnosis.

To use an analogy, let’s say you have a 15-year-old kid who is clearly college-bound, but as your income has grown and you’re approaching mid-life, you have your eye on a $50,000 BMW Z4. You’ll have to finance either on, which means projecting interest payments over a number of years. Also, if you buy the car, there will be time-and-money maintenance costs. While they are not equivalent in emotional value, you want the biggest satisfaction while spending the least money over time. Either choice comes with opportunity costs, but if possible, you want both.

Essentially, the Callender study approached saving men from PCa-related mortality in much the same way. Can we preserve both life and quality of life while spending less over time? We already know the opportunity cost of the current conventional pathway is very expensive. Again, taking into account the initial investment and longer-term payments for MRI equipment, trained radiologists, and scanning time/price, is it still possible to save significant costs down the line? The answer is, yes!

The biggest bang for the healthcare buck and men’s quality of life

In both MRI-first strategies (age based; risk stratified) the authors determined that each of them was more beneficial and cost effective than any biopsy-first strategy. In fact, “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.”

The Callender study supports what Sperling Prostate Center is all about: more personal benefits, fewer medical costs in the future. Contact us to arrange a consultation.

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.