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Yee CW, Harvey MJ, Xin Y, Kirson NY. Cost-Effectiveness Modeling of Prostate-Specific Membrane Antigen Positron Emission Tomography with Piflufolastat F 18 for the Initial Diagnosis of Patients with Prostate Cancer in the United States. PHARMACOECONOMICS 2024; 42:231-247. [PMID: 37934376 PMCID: PMC10811023 DOI: 10.1007/s40273-023-01322-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/01/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Piflufolastat F 18 is a novel prostate-specific membrane antigen (PSMA)-targeted positron emission tomography (PET) radiotracer that is superior to standard of care (SOC) imaging for the initial staging of prostate cancer and the detection of biochemical recurrence. As piflufolastat F 18 has been approved in the United States (US) for this indication, this modeling study assessed the cost effectiveness of piflufolastat F 18 versus fluciclovine F-18, gallium68-PSMA-11 (PSMA 11), and SOC imaging (a mix of bone scans, computed tomography, and magnetic resonance imaging) for the diagnosis and staging of prostate cancer from a US healthcare system perspective. PERSPECTIVE A US third-party payer perspective was used, which for this population reflects a mix of commercial and Medicare, considering only direct healthcare costs. SETTING This study utilized a tertiary healthcare setting. METHODS A decision tree was used to map the diagnostic/treatment pathway, consisting of the proportion of patients with local, regional, distant, or no disease; prostate-specific antigen (PSA) ≤ 1.0 or > 1.0; and accuracy of imaging modalities. A Markov model predicted the long-term outcomes of disease progression according to treatment decisions. Inputs to the model were informed by data from the OSPREY and CONDOR clinical trials, public data, and the literature. Treatment mix included active surveillance, radiation therapy, prostatectomy, androgen deprivation therapy (ADT), and radiation therapy + ADT, informed by expert opinion. Outcomes included life-years (LY), quality-adjusted life-years (QALY), and the incremental cost-effectiveness ratio (ICER). All costs were reported in 2021 US dollars, using the US Bureau of Labor Statistics Consumer Price Index. A willingness-to-pay (WTP) threshold of $150,000 was considered cost effective, consistent with the upper range used as the standard for price benchmarks by the Institute for Clinical and Economic Review. The robustness of the base-case results was assessed in deterministic and probabilistic sensitivity analyses. RESULTS Over a lifetime horizon, piflufolastat F 18 had the greatest effectiveness in terms of LYs (6.80) and QALYs (5.33); for the comparators, LYs ranged from 6.58 (SOC) to 6.76 (PSMA 11) and QALYs ranged from 5.12 (SOC) and 5.30 (PSMA 11). Piflufolastat F 18 was more cost effective compared with fluciclovine F 18, PSMA 11, and SOC, with ICERs of $21,122, $55,836, and $124,330 per QALY gained, respectively. Piflufolastat F 18 was associated with the greatest net monetary benefit ($627,918) compared with the other options at a WTP threshold of $150,000. The results of the deterministic and probabilistic sensitivity analyses supported the robustness of the base-case results. CONCLUSIONS This study suggests that piflufolastat F 18 is a cost-effective diagnostic option for men with prostate cancer in the US, with higher associated LY, QALY, and greater net monetary benefit than fluciclovine F 18, PSMA 11, and SOC imaging.
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Wang Y, Galante JR, Haroon A, Wan S, Afaq A, Payne H, Bomanji J, Adeleke S, Kasivisvanathan V. The future of PSMA PET and WB MRI as next-generation imaging tools in prostate cancer. Nat Rev Urol 2022; 19:475-493. [PMID: 35789204 DOI: 10.1038/s41585-022-00618-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 11/09/2022]
Abstract
Radiolabelled prostate-specific membrane antigen (PSMA)-based PET-CT has been shown in numerous studies to be superior to conventional imaging in the detection of nodal or distant metastatic lesions. 68Ga-PSMA PET-CT is now recommended by many guidelines for the detection of biochemically relapsed disease after radical local therapy. PSMA radioligands can also function as radiotheranostics, and Lu-PSMA has been shown to be a potential new line of treatment for metastatic castration-resistant prostate cancer. Whole-body (WB) MRI has been shown to have a high diagnostic performance in the detection and monitoring of metastatic bone disease. Prospective, randomized, multicentre studies comparing 68Ga-PSMA PET-CT and WB MRI for pelvic nodal and metastatic disease detection are yet to be performed. Challenges for interpretation of PSMA include tracer trapping in non-target tissues and also urinary excretion of tracers, which confounds image interpretation at the vesicoureteral junction. Additionally, studies have shown how long-term androgen deprivation therapy (ADT) affects PSMA expression and could, therefore, reduce tracer uptake and visibility of PSMA+ lesions. Furthermore, ADT of short duration might increase PSMA expression, leading to the PSMA flare phenomenon, which makes the accurate monitoring of treatment response to ADT with PSMA PET challenging. Scan duration, detection of incidentalomas and presence of metallic implants are some of the major challenges with WB MRI. Emerging data support the wider adoption of PSMA PET and WB MRI for diagnosis, staging, disease burden evaluation and response monitoring, although their relative roles in the standard-of-care management of patients are yet to be fully defined.
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Affiliation(s)
- Yishen Wang
- School of Clinical Medicine, University of Cambridge, Cambridge, UK. .,Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK.
| | - Joao R Galante
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Athar Haroon
- Department of Nuclear Medicine, Barts Health NHS Trust, London, UK
| | - Simon Wan
- Institute of Nuclear Medicine, University College London, London, UK
| | - Asim Afaq
- Institute of Nuclear Medicine, University College London, London, UK.,Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Jamshed Bomanji
- Institute of Nuclear Medicine, University College London, London, UK
| | - Sola Adeleke
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
| | - Veeru Kasivisvanathan
- Division of Surgery & Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
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Comparing the diagnostic performance of radiotracers in prostate cancer biochemical recurrence: a systematic review and meta-analysis. Eur Radiol 2022; 32:7374-7385. [PMID: 35486169 PMCID: PMC9668945 DOI: 10.1007/s00330-022-08802-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/27/2022] [Accepted: 04/04/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To systematically assess the early detection rate of biochemical prostate cancer recurrence using choline, fluciclovine, and PSMA. METHODS Under the guidance of the Preferred Reporting Items for Systematic reviews and Meta-Analysis Diagnostic Test Accuracy guidelines, literature that assessed the detection rates (DRs) of choline, fluciclovine, and PSMA in prostate cancer biochemical recurrence was searched in PubMed and EMBASE databases for our systematic review from 2012 to July 15, 2021. In addition, the PSA-stratified performance of detection positivity was obtained to assess the DRs for various methods, including fluciclovine, PSMA, or choline PET/CT, with respect to biochemical recurrence based on different PSA levels. RESULTS In total, 64 studies involving 11,173 patients met the inclusion criteria. Of the studies, 12, 7, and 48 focused on choline, fluciclovine, and PSMA, respectively. The pooled DRs were 24%, 37%, and 44%, respectively, for a PSA level less than 0.5 ng/mL (p < 0.001); 36%, 44%, and 60% for a PSA level of 0.5-0.99 ng/mL (p < 0.001); and 50%, 61%, and 80% for a PSA level of 1.0-1.99 ng/mL (p < 0.001). The DR with 18F-labeled PSMA was higher than that with 68Ga-labeled PSMA, and the DR was 58%, 72%, and 88% for PSA levels < 0.5 ng/mL, 0.5-0.9 ng/mL, and 1.0-1.99 ng/mL, respectively. CONCLUSION The DRs of PSMA-radiotracers were greater than those of choline-radiotracers and fluciclovine-radiotracers at the patient level. 18F-labeled PSMA achieved a higher DR than 68Ga-labeled PSMA. KEY POINTS • The DRs of PSMA-radiotracers were greater than those of choline-radiotracers and fluciclovine-radiotracers at the patient level. • 18F-labeled PSMA achieved a higher DR than 68Ga-labeled PSMA.
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Kalinauskaite G, Senger C, Kluge A, Furth C, Kufeld M, Tinhofer I, Budach V, Beck M, Hochreiter A, Grün A, Stromberger C. 68Ga-PSMA-PET/CT-based radiosurgery and stereotactic body radiotherapy for oligometastatic prostate cancer. PLoS One 2020; 15:e0240892. [PMID: 33085712 PMCID: PMC7577453 DOI: 10.1371/journal.pone.0240892] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/05/2020] [Indexed: 02/07/2023] Open
Abstract
Background Androgen deprivation therapy (ADT) remains the standard therapy for patients with oligometastatic prostate cancer (OMPC). Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT)-based stereotactic body radiotherapy (SBRT) is emerging as an alternative option to postpone starting ADT and its associated side effects including the development of drug resistance. The aim of this study was to determine progression free-survival (PFS) and treatment failure free-survival (TFFS) after PSMA-PET/CT-based SBRT in OMPC patients. The efficacy and safety of single fraction radiosurgery (SFRS) and ADT delay were investigated. Methods Patients with ≤5 metastases from OMPC, with/without ADT treated with PSMA-PET/CT-based SBRT were retrospectively analyzed. PFS and TFFS were primary endpoints. Secondary endpoints were local control (LC), overall survival (OS) and ADT-free survival (ADTFS). Results Fifty patients with a total of 75 metastases detected by PSMA-PET/CT were analyzed. At the time of SBRT, 70% of patients were castration-sensitive. Overall, 80% of metastases were treated with SFRS (median dose 20 Gy, range: 16–25). After median follow-up of 34 months (range: 5–70) median PFS and TFFS were 12 months (range: 2–63) and 14 months (range: 2–70), respectively. Thirty-two (64%) patients had repeat oligometastatic disease. Twenty-four (48%) patients with progression underwent second SBRT course. Two-year LC after SFRS was 96%. Grade 1 and 2 toxicity occurred in 3 (6%) and 1 (2%) patients, respectively. ADTFS and OS rates at 2-years were 60.5% and 100%, respectively. In multivariate analysis, TFFS significantly improved in patients with time to first metastasis (TTM) >36 months (p = 0.01) and PSA before SBRT ≤1 ng/ml (p = 0.03). Conclusion For patients with OMPC, SBRT might be used as an alternative to ADT. This way, the start/escalation of palliative ADT and its side effects can be deferred. Metastases treated with PSMA-PET/CT-based SFRS reached excellent LC with minimal toxicity. Low PSA levels and longer TTM predict elongated TFFS.
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Affiliation(s)
- Goda Kalinauskaite
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology and Radiotherapy, Berlin, Germany
- Charité CyberKnife Center, Departments of Radiation Oncology and Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
- * E-mail:
| | - Carolin Senger
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology and Radiotherapy, Berlin, Germany
- Charité CyberKnife Center, Departments of Radiation Oncology and Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anne Kluge
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology and Radiotherapy, Berlin, Germany
- Charité CyberKnife Center, Departments of Radiation Oncology and Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Furth
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Berlin, Germany
| | - Markus Kufeld
- Charité CyberKnife Center, Departments of Radiation Oncology and Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ingeborg Tinhofer
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology and Radiotherapy, Berlin, Germany
- The Translational Radiooncology and Radiobiology Research Laboratory, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Volker Budach
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology and Radiotherapy, Berlin, Germany
- Charité CyberKnife Center, Departments of Radiation Oncology and Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus Beck
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology and Radiotherapy, Berlin, Germany
- Charité CyberKnife Center, Departments of Radiation Oncology and Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alexandra Hochreiter
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology and Radiotherapy, Berlin, Germany
| | - Arne Grün
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology and Radiotherapy, Berlin, Germany
- Charité CyberKnife Center, Departments of Radiation Oncology and Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Carmen Stromberger
- Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology and Radiotherapy, Berlin, Germany
- Charité CyberKnife Center, Departments of Radiation Oncology and Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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