Cost consideration in utilization of multiparametric magnetic resonance imaging in prostate cancer

Has Active Surveillance for Prostate Cancer Become Safer? Lessons Learned from a Global Clinical Registry

BACKGROUND AND OBJECTIVE

Active surveillance (AS) has evolved into a widely applied treatment strategy for many men around the world with low-risk prostate cancer (or in selected cases intermediate-risk disease). Here, we report on the safety and acceptability of AS, and treatment outcomes for low- and intermediate-risk tumours over time in 14 623 men with follow-up of over 6 yr.

METHODS

Clinical data from 26 999 men on AS from 25 cohorts in 15 countries have been collected in an international database from 2000 onwards.

KEY FINDINGS AND LIMITATIONS

Across our predefined four time periods of 4 yr each (covering the period 2000-2016), there was no significant change in overall survival (OS). However, metastasis-free survival (MFS) rates have improved since the second period and were excellent (>99%). Treatment-free survival rates for earlier periods showed a slightly more rapid shift to radical treatment. Over time, there was a constant proportion of 5% of men for whom anxiety was registered as the reason for treatment alteration. There was, however, also a subset of 10-15% in whom treatment was changed, for which no apparent reason was available. In a subset of men (10-15%), tumour progression was the trigger for treatment. In men who opted for radical treatment, surgery was the most common treatment modality. In those men who underwent radical treatment, 90% were free from biochemical recurrence at 5 yr after treatment.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our study confirms that AS was a safe management option over the full duration in this large multicentre cohort with long-term follow-up, given the 84.1% OS and 99.4% MFS at 10 yr. The probability of treatment at 10 yr was 20% in men with initial low-risk tumours and 31% in men with intermediate-risk tumours. New diagnostic modalities may improve the acceptability of follow-up using individual risk assessments, while safely broadening the use of AS in higher-risk tumours.

PATIENT SUMMARY

Active surveillance (AS) has evolved into a widely applied treatment strategy for many men with prostate cancer around the world. In this report, we show the long-term safety of following AS for men with low- and intermediate-risk prostate cancer. Our study confirms AS as a safe management option for low- and intermediate-risk prostate cancer. New diagnostic modalities may improve the acceptability of follow-up using individual risk assessments, while safely broadening the use of AS in higher-risk tumours.

Performance of cognitive vs. image-guided fusion biopsy for detection of overall and clinically significant prostate cancer in a multiethnic population

PURPOSE

Transrectal ultrasound-guided prostate biopsy remains the most used method for the detection of prostate cancer. We recently reported that detection of clinically significant prostate cancer (cs-CaP) using image-guided fusion biopsies (IGFB) varied by race/ethnicity, which calls for further comparison between cognitive fusion biopsy (CFB) and IGFB among non-Hispanic black and Hispanic populations. Therefore, the aim of our study is to compare the rates of detection of cs-CaP and overall CaP by CFB and IGFB in a multiethnic community.

MATERIAL AND METHODS

We performed a retrospective, cross-sectional review of men who underwent MRI-transrectal ultrasound-guided prostate biopsy at our diverse, urban academic medical center. Agreement and discordance between fusion biopsies and systematic biopsies for detection of cs-CaP and overall CaP were determined using Kappa statistics. Univariate and multivariate mixed-effects logistic regression models were used to find associations between fusion modalities and prostate cancer detection.

RESULTS

In total, 710 men underwent fusion prostate biopsies between December 2015 and June 2021. Upon univariate and multivariate logistic regression analysis, there was no significant association between IGFB vs. CFB and risk of overall CaP (OR = 0.66, 95% CI: 0.36-1.21, P = 0.18) or cs-CaP (OR = 0.57, 95% CI: 0.30-1.08, P = 0.09). We found moderate agreement between fusion and systematic biopsies for both CFB (κ = 0.56) and IGFB (κ = 0.52) in cs-CaP.

CONCLUSIONS

CFB and IGFB offer similar detection rates of cs-CaP in a multiethnic population. CFB represents an effective and accessible means of accurately diagnosing prostate cancer.

Increased magnetic resonance imaging in prostate cancer management-What are the outcomes?

RATIONALE

Increased attention to cancer care has instigated altered systems for screening, diagnosis, and management of various types of cancer, such as in the prostate. While such systems very likely have improved the quality of cancer care, they also result in the altered use of specific services, such as magnetic resonance imaging (MRI).

AIMS AND OBJECTIVE

To study the change in the use of prostate MRI in the Norwegian health care system from 2013 to 2021 and to investigate some reasons for and potential implications of this change.

METHOD

Data from the Norwegian Health Economics Administration (HELFO), The Cancer Registry of Norway and Cause-of-death registry at the Norwegian Institute of public health and the health registry of Vestfold Hospital Trust were used for descriptive statistical analysis.

RESULTS

The number of MRIs of the prostate increased threefold from 2013 to 2021, representing an extra cost of 2 million USD in 2020. The incidence of prostate cancer was stable at about 5000 cases per year, corresponding to 178 per 100,000 men, indicating no increased overdiagnosis. However, the clinical staging has changed substantially during this period, indicating stage and grade migration. The number of negative biopsies was reduced, and there are three MRIs per reduced negative biopsy. The number of persons on active surveillance increased during the period. However, these changes are partly independent of the increase in the number of MRIs.

CONCLUSION

There was a substantial increase in the number of prostate MRIs and thus an increase in costs. This appears to have contributed to the reduction of negative biopsies, improved staging and increased active surveillance. However, as these effects are partly independent of the increase in MRIs, we need to document the outcomes for patients from prostate MRIs as their opportunity costs are substantial.

A Review of PRESAGE Radiochromic Polymer and the Compositions for Application in Radiotherapy Dosimetry

Recent advances in radiotherapy technology and techniques have allowed a highly conformal radiation to be delivered to the tumour target inside the body for cancer treatment. A three-dimensional (3D) dosimetry system is required to verify the accuracy of the complex treatment delivery. A 3D dosimeter based on the radiochromic response of a polymer towards ionising radiation has been introduced as the PRESAGE dosimeter. The polyurethane dosimeter matrix is combined with a leuco-dye and a free radical initiator, whose colour changes in proportion to the radiation dose. In the previous decade, PRESAGE gained improvement and enhancement as a 3D dosimeter. Notably, PRESAGE overcomes the limitations of its predecessors, the Fricke gel and the polymer gel dosimeters, which are challenging to fabricate and read out, sensitive to oxygen, and sensitive to diffusion. This article aims to review the characteristics of the radiochromic dosimeter and its clinical applications. The formulation of PRESAGE shows a delicate balance between the number of radical initiators, metal compounds, and catalysts to achieve stability, optimal sensitivity, and water equivalency. The applications of PRESAGE in advanced radiotherapy treatment verifications are also discussed.

A narrative review of biparametric MRI (bpMRI) implementation on screening, detection, and the overall accuracy for prostate cancer

Prostate cancer is the most common malignancy in American men following skin cancer, with approximately one in eight men being diagnosed during their lifetime. Over the past several decades, the treatment of prostate cancer has evolved rapidly, so too has screening. Since the mid-2010s, magnetic resonance imaging (MRI)–guided biopsies or ‘targeted biopsies’ has been a rapidly growing topic of clinical research within the field of urologic oncology. The aim of this publication is to provide a review of biparametric MRI (bpMRI) utilization for the diagnosis of prostate cancer and a comparison to multiparametric MRI (mpMRI). Through single-centered studies and meta-analysis across all identified pertinent published literature, bpMRI is an effective tool for the screening and diagnosis of prostate cancer. When compared with the diagnostic accuracy of mpMRI, bpMRI identifies prostate cancer at comparable rates. In addition, when omitting dynamic contrast-enhanced (DCE) protocol to the MRI, patients incur reduced costs and shorter imaging time while providers can offer more tests to their patient population.

A Head-to-head Comparison of Prostate Cancer Diagnostic Strategies Using the Stockholm3 Test, Magnetic Resonance Imaging, and Swedish National Guidelines: Results from a Prospective Population-based Screening Study

Background

Strategies for early detection of prostate cancer aim to detect clinically significant prostate cancer (csPCa) and avoid detection of insignificant cancers and unnecessary biopsies. Swedish national guidelines (SNGs), years 2019 and 2020, involve prostate-specific antigen (PSA) testing, clinical variables, and magnetic resonance imaging (MRI). The Stockholm3 test and MRI have been suggested to improve selection of men for prostate biopsy. Performance of SNGs compared with the Stockholm3 test or MRI in a screening setting is unclear.

Objective

To compare strategies based on previous and current national guidelines, Stockholm3, and MRI to select patients for biopsy in a screening-by-invitation setting.

Design, setting, and participants

All participants underwent PSA test, and men with PSA ≥3 ng/ml underwent Stockholm3 testing and MRI. Men with Stockholm3 ≥11%, Prostate Imaging Reporting and Data System score ≥3 on MRI, or indication according to SNG-2019 or SNG-2020 were referred to biopsy.

Outcome measurements and statistical analysis

The primary outcome was the detection of csPCa at prostate biopsy, defined as an International Society of Urological Pathology (ISUP) grade of ≥2.

Results and limitations

We invited 8764 men from the general population, 272 of whom had PSA ≥3 ng/ml. The median PSA was 4.1 (interquartile range: 3.4–5.8), and 136 of 270 (50%) who underwent MRI lacked any pathological lesions. In total, 37 csPCa cases were diagnosed. Using SNG-2019, 36 csPCa cases with a high biopsy rate (179 of 272) were detected and 49 were diagnosed with ISUP 1 cancers. The Stockholm3 strategy diagnosed 32 csPCa cases, with 89 biopsied and 27 ISUP 1 cancers. SNG-2020 detected 32 csPCa and 33 ISUP 1 cancer patients, with 99 men biopsied, and the MRI strategy detected 30 csPCa and 35 ISUP 1 cancer cases by biopsying 123 men. The latter two strategies generated more MRI scans than the Stockholm3 strategy (n = 270 vs 33).

Conclusions

Previous guidelines provide high detection of significant cancer but at high biopsy rates and detection of insignificant cancer. The Stockholm3 test may improve diagnostic precision compared with the current guidelines or using only MRI.

Patient summary

The Stockholm3 test facilitates detection of significant cancer, and reduces the number of biopsies and detection of insignificant cancer.

MRI as a screening tool for prostate cancer: current evidence and future challenges

Purpose

Prostate cancer (PCa) screening, which relies on prostate-specific antigen (PSA) testing, is a contentious topic that received negative attention due to the low sensitivity and specificity of PSA to detect clinically significant PCa. In this context, due to the higher sensitivity and specificity of magnetic resonance imaging (MRI), several trials investigate the feasibility of “MRI-only” screening approaches, and question if PSA testing may be replaced within prostate cancer screening programs.

Methods

This narrative review discusses the current literature and the outlook on the potential of MRI-based PCa screening.

Results

Several prospective randomized population-based trials are ongoing. Preliminary study results appear to favor the “MRI-only” approach. However, MRI-based PCa screening programs face a variety of obstacles that have yet to be fully addressed. These include the increased cost of MRI, lack of broad availability, differences in MRI acquisition and interpretation protocols, and lack of long-term impact on cancer-specific mortality. Partly, these issues are being addressed by shorter and simpler MRI approaches (5–20 min bi-parametric MRI), novel quality indicators (PI-QUAL) and the implementation of radiomics (deep learning, machine learning).

Conclusion

Although promising preliminary results were reported, MRI-based PCa screening still lack long-term data on crucial endpoints such as the impact of MRI screening on mortality. Furthermore, the issues of availability, cost-effectiveness, and differences in MRI acquisition and interpretation still need to be addressed.

The urologist's learning curve of "in-bore" magnetic resonance-guided prostate biopsy

Background

The combination of multi-parametric MRI to locate and define suspected lesions together with their being targeted by an MRI-guided prostate biopsy has succeeded in increasing the detection rate of clinically significant disease and lowering the detection rate of non-significant prostate cancer. In this work we investigate the urologist’s learning curve of in-bore MRI-guided prostate biopsy which is considered to be a superior biopsy technique.

Materials and methods

Following Helsinki approval by The Chaim Sheba Medical Center ethics committee in accordance with The Sheba Medical Center institutional guidelines (5366-28-SMC) we retrospectively reviewed 110 IB-MRGpBs performed from 6/2016 to 1/2019 in a single tertiary center. All patients had a prostate multi-parametric MRI finding of at least 1 target lesion (prostate imaging reporting and data system [PI-RADS] score ≥ 3). We analyzed biopsy duration and clinically significant prostate cancer detection of targeted sampling in 2 groups of 55 patients each, once by a urologist highly trained in IB-MRGpBs and again by a urologist untrained in IB-MRGpBs. These two parameters were compared according to operating urologist and chronologic order.

Results

The patients’ median age was 68 years (interquartile range 62–72). The mean prostate-specific antigen level and prostate size were 8.6 ± 9.1 ng/d and 53 ± 27 cc, respectively. The mean number of target lesions was 1.47 ± 0.6. Baseline parameters did not differ significantly between the 2 urologists’ cohorts. Overall detection rates of clinically significant prostate cancer were 19%, 55%, and 69% for PI-RADS 3, 4 and 5, respectively. Clinically significant cancer detection rates did not differ significantly along the timeline or between the 2 urologists. The average duration of IB-MRGpB targeted sampling was 28 ± 15.8 min, correlating with the number of target lesions (p < 0.0001), and independent of the urologist’s expertise. Eighteen cases defined the cutoff for the procedure duration learning curve (p < 0.05).

Conclusions

Our data suggest a very short learning curve for IB-MRGpB-targeted sampling duration, and that clinically significant cancer detection rates are not influenced by the learning curve of this technique.

How Should Molecular Markers and Magnetic Resonance Imaging Be Used in the Early Detection of Prostate Cancer?

The literature gives limited data or guidance on how to select or combine biomarkers and magnetic resonance imaging (MRI) for the early detection of prostate cancer. We strongly recommend prospective studies large enough to address questions such as the properties of biomarkers in cases with high versus low Prostate Imaging-Reporting and Data System scores or the correlation between biomarkers and MRI, and that evaluate results in the context of reasonable clinical scenarios.

Impact of the MyProstateScore (MPS) Test on the Clinical Decision to Undergo Prostate Biopsy: Results From a Contemporary Academic Practice

OBJECTIVE

To evaluate the association of the MyProstateScore (MPS) urine test on the decision to undergo biopsy in men referred for prostate biopsy in urology practice.

METHODS

MPS testing was offered as an alternative to immediate biopsy in men referred to the University of Michigan for prostate biopsy from October 2013 through October 2016. The primary endpoint was the decision to perform biopsy. The proportion of patients undergoing biopsy was compared to predicted risk scores from the Prostate Cancer Prevention Trial risk calculator (PCPTrc). Analyses were stratified by the use of multiparametric magnetic resonance imaging (mpMRI). The associations of PCPTrc, MPS, and mpMRI with the decision to undergo biopsy were explored in a multivariable logistic regression model.

RESULTS

Of 248 patients, 134 (54%) proceeded to prostate biopsy. MPS was significantly higher in biopsied patients (median 29 vs14, P < .001). The use of biopsy was strongly associated with MPS, with biopsy rates of 26%, 38%, 58%, 90%, and 85% in the first through fifth quintiles, respectively (P < .001). MPS association with biopsy persisted upon stratification by mpMRI. On multivariable analysis, MPS was strongly associated with the decision to undergo biopsy when modeled as both a continuous (odds ratio [OR] 1.05, 95%; confidence interval [CI] 1.04-1.08; <.001) and binary (OR 7.76, 95%; CI 4.14-14.5; P < .001) variable.

CONCLUSION

Many patients (46%) undergoing clinical MPS testing as an alternative to immediate prostate biopsy were able to avoid biopsy. Increasing MPS was strongly associated with biopsy rates. These findings were robust to use of mpMRI.

Contrast-enhanced ultrasound with dispersion analysis for the localization of prostate cancer: correlation with radical prostatectomy specimens

PURPOSE

To determine the value of two-dimensional (2D) contrast-enhanced ultrasound (CEUS) imaging and the additional value of contrast ultrasound dispersion imaging (CUDI) for the localization of clinically significant prostate cancer (csPCa).

METHODS

In this multicentre study, subjects scheduled for a radical prostatectomy underwent 2D CEUS imaging preoperatively. CUDI maps were generated from the CEUS recordings. Both CEUS recordings and CUDI maps were scored on the likelihood of presenting csPCa (any Gleason ≥ 4 + 3 and Gleason 3 + 4 larger than 0.5 mL) by five observers and compared to radical prostatectomy histopathology. An automated three-dimensional (3D) fusion protocol was used to match imaging with histopathology. Receiver operator curve (ROC) analysis was performed per observer and imaging modality.

RESULTS

133 of 216 (62%) patients were included in the final analysis. Average area under the ROC for all five readers for CEUS, CUDI and the combination was 0.78, 0.79 and 0.78, respectively. This yields a sensitivity and specificity of 81 and 64% for CEUS, 83 and 56% for CUDI and 83 and 55% for the combination. Interobserver agreement for CEUS, CUDI and the combination showed kappa values of 0.20, 0.18 and 0.18 respectively.

CONCLUSION

The sensitivity and specificity of 2D CEUS and CUDI for csPCa localization are moderate. Despite compressing CEUS in one image, CUDI showed a similar performance to 2D CEUS. With a sensitivity of 83% at cutoff point 3, it could become a useful imaging procedure, especially with 4D acquisition, improved quantification and combination with other US imaging techniques such as elastography.

Evaluation of Apparent Diffusion Coefficient as a Predictor of Grade Reclassification in Men on Active Surveillance for Prostate Cancer

OBJECTIVE

To evaluate the association between apparent diffusion coefficient (ADC) on initial multiparametric MRI (mpMRI) and biopsy grade reclassification (GR) to grade group (GG) ≥2 prostate cancer (CaP) in men on active surveillance (AS) with GG 1 CaP.

METHODS

We retrospectively identified 242 AS patients with reported ADC values on their initial mpMRI. ADC value from the index lesion was assessed as an independent predictor of GR using a Cox model. To ease clinical interpretation, we used a log-rank test to establish an ADC cutoff of 1128 × 10^-6 mm²/s for Kaplan-Meier analysis.

RESULTS

Of the 242 men, 70 underwent GR following initial mpMRI, of which 26 (37%) had GR at the index lesion. There was no significant difference in the median interval between biopsies for men with and without GR (P >.9). Men with GR had significantly lower median ADC than those without GR (P = .01). In multivariable analysis adjusting for age, prostate-specific antigen density, and National Comprehensive Cancer Network risk group, a 100-unit decrease in ADC was associated with a 12% increase in the risk of GR (HR = 1.12, 95% CI: 1.01-1.22, P = .03). Two- and 4-year rates of freedom from GR were significantly lower for men with ADC <1128 × 10^-6 mm²/s vs ADC ≥1128 × 10^-6 mm²/s (62% and 42% vs 78% and 68%, respectively; P <.001).

CONCLUSION

For AS patients, lower ADC on initial mpMRI index lesion is associated with increased risk of GR to GG ≥2 CaP and would be a useful component of multivariable risk prediction tools.

Determining Clinically Based Factors Associated With Reclassification in the Pre-MRI Era using a Large Prospective Active Surveillance Cohort

OBJECTIVE

To report biopsy-related and oncologic outcomes in a large prospective active surveillance cohort that was initiated in the premagnetic resonance imaging era and to additionally identify clinical factors associated with disease reclassification in order to inform future studies designed to improve enrollment and follow-up on active surveillance.

METHODS

Patients were prospectively enrolled at a single institution from 2006 to 2014 and followed until 2016. Men with Gleason 6 or 7 disease were eligible, and those with >6 months follow-up were included in the analysis. Patients were risk stratified based on clinical/pathologic criteria, including based on a combination of baseline and confirmatory biopsy tumor characteristics. Reclassification-free survival, based on tumor volume increase or Gleason score increase, was analyzed using multivariable Cox proportional hazards models.

RESULTS

Of 825 enrolled patients, 682 met inclusion criteria. Median follow-up was 40 months (range 6.6-126.8). Disease was reclassified in 249 (36.5%), and 157 (23.0%) underwent treatment. A single positive core with a negative confirmatory biopsy was significantly associated with time to reclassification (median not met vs 43 months, log rank test P <.001). Composite tumor length, defined as the combined tumor length between baseline and confirmatory biopsies, was associated with shorter Gleason upgrade-free survival (hazard ratio 1.24, 95% confidence interval 1.11-1.40, P <.001) in multivariable analysis.

CONCLUSION

Baseline stratification using clinical factors including tumor length may refine risk stratification and offer the foundation on which new systems that incorporate modalities such as magnetic resonance imaging may be based.

Evolution of prostate MRI: from multiparametric standard to less-is-better and different-is better strategies

Multiparametric magnetic resonance imaging (mpMRI) has become the standard of care to achieve accurate and reproducible diagnosis of prostate cancer. However, mpMRI is quite demanding in terms of technical rigour, patient's tolerability and safety, expertise in interpretation, and costs. This paper reviews the main technical strategies proposed as less-is-better solutions for clinical practice (non-contrast biparametric MRI, reduction of acquisition time, abbreviated protocols, computer-aided diagnosis systems), discussing them in the light of the available evidence and of the concurrent evolution of Prostate Imaging Reporting and Data System (PI-RADS). We also summarised research results on those advanced techniques representing an alternative different-is-better line of the still ongoing evolution of prostate MRI (quantitative diffusion-weighted imaging, quantitative dynamic contrast enhancement, intravoxel incoherent motion, diffusion tensor imaging, diffusional kurtosis imaging, restriction spectrum imaging, radiomics analysis, hybrid positron emission tomography/MRI).

Perceptions of Prostate MRI and Fusion Biopsy of Radiation Oncologists and Urologists for Patients Diagnosed with Prostate Cancer: Results from a National Survey

BACKGROUND

Magnetic resonance imaging (MRI) of the prostate and fusion biopsy have been advanced to improve the detection of clinically significant prostate cancer (PCa). Yet, frequency of their use and contemporary attitudes among radiation oncologists (ROs) and urologists (UROs) remain largely unknown.

OBJECTIVE

We performed a national survey of UROs and ROs to assess the perceived attitudes towards and frequency of prostate MRI and fusion biopsy.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a national survey of 915 ROs and 940 UROs about prostate MRI and fusion biopsy in 2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The survey queried respondents about perceptions of prostate MRI and fusion biopsy and inquired about self-reported utilization. Pearson chi-square test and multivariable logistic regression were used to identify physician characteristics associated with survey responses.

RESULTS AND LIMITATIONS

The overall response rate was 37% (n=691). Both UROs and ROs demonstrated similar positive views that MRI with fusion biopsy improves PCa risk stratification (67% vs 71%; p=0.19) and fusion biopsy increases the confidence recommending active surveillance (55% vs 60%; p=0.18). Yet, only a quarter of both specialties reported frequent use of prostate MRI for treatment decisions for low- and intermediate-risk PCa. Compared with respondents practicing in community practices, those in academic practices were more likely to report using prostate MRI for low- (44% vs 19%; adjusted odds ratio [OR]: 3.96; p<0.001) and intermediate-risk PCa (42% vs 24%; adjusted OR: 2.49; p<0.001). Our study was limited by a modestly lower response rate.

CONCLUSIONS

While both specialties have perceived value in favor of prostate MRI and fusion biopsy, only a quarter of respondents report their use in clinical practice. Physicians practicing in academic medical centers had greater self-reported use.

PATIENT SUMMARY

Magnetic resonance imaging of the prostate and targeted biopsies have growing evidence of their use as a superior diagnostic methodology for prostate cancer diagnosis and treatment decisions. Our survey study found that a majority of radiation oncologists and urologists view both favorably in improving prostate cancer detection and treatment decisions. Yet, only a quarter report using it in routine clinical practice for men diagnosed with prostate cancer.

A narrative review and update on management following negative prostate biopsy

PURPOSE OF REVIEW

Prostate cancer has traditionally been diagnosed using systematic transrectal ultrasound-guided biopsy. However, given the inherent nature of sampling, a negative biopsy does not exclude clinically significant prostate cancer (csPCa), and continued controversy exists in the optimal management following initial biopsy. Numerous avenues for evaluation include multiparametric MRI (mpMRI), use of molecular biomarkers, repeat biopsy, and observation.

RECENT FINDINGS

mpMRI has shown promise in guiding further biopsy management: for individuals with identified target lesions, increased accuracy and detection using combination targeted and systematic sampling has been repeatedly demonstrated in the literature as an effective strategy. For those with negative MRIs and/or negative biomarker (blood, urinary, tissue) studies, increasing evidence has suggested that these individuals may be able to avoid biopsy altogether, albeit at a small risk of missing csPCa. Observation should be based on an individual's risk of csPCa versus their competing health risks, and saturation biopsy reserved for rare cases with high clinical suspicion.

SUMMARY

Management following an initial negative prostate biopsy requires careful discussion with the patient, their risk tolerance, and threshold for intervention. Although subject to availability, mpMRI and molecular biomarkers may better risk stratify patients, identify target lesions, and in certain cases, spare biopsy altogether.

Cost and cost-effectiveness studies in urologic oncology using large administrative databases

OBJECTIVE

Urologic cancers are not only among the most common types of cancers, but also among the most expensive cancers to treat in the United States. This study aimed to review the use of CEAs and other cost analyses in urologic oncology using large databases to better understand the value of management strategies of these cancers.

METHODS

A literature review on CEAs and other cost analyses in urologic oncology using large databases.

RESULTS

The options for and costs of diagnosing, treating, and following patients with urologic cancers can be expected to rise in the coming years. There are numerous opportunities in each urologic cancer to use CEAs to both lower costs and provide high-quality services. Improved cancer care must balance the integration of novelty with ensuring reasonable costs to patients and the health care system.

CONCLUSION

With the increasing focus cost containment, appreciating the value of competing strategies in caring for our patients is pivotal. Leveraging methods such as CEAs and harnessing large databases may help evaluate the merit of established or emerging strategies.