Incorporating Biomarkers into the Primary Prostate Biopsy Setting: A Cost-Effectiveness Analysis

PURPOSE

We performed a cost-effectiveness analysis using the PHI (Prostate Health Index), 4Kscore®, SelectMDx™ and the EPI (ExoDx™ Prostate [IntelliScore]) in men with elevated prostate specific antigen to determine the need for biopsy.

MATERIALS AND METHODS

We developed a decision analytical model in men with elevated prostate specific antigen (3 ng/ml or greater) in which 1 biomarker test was used to determine which hypothetical individuals required biopsy. In the current standard of care strategy all individuals underwent biopsy. Model parameters were derived from a comprehensive review of the literature. Costs were calculated from a health sector perspective and converted into 2017 United States dollars.

RESULTS

The cost and QALYs (quality adjusted life-years) of the current standard of care, which was transrectal ultrasound guided biopsy, was $3,863 and 18.085, respectively. Applying any of the 3 biomarkers improved quality adjusted survival compared to the current standard of care. The cost of SelectMDx, the PHI and the EPI was lower than performing prostate biopsy in all patients. However, the PHI was more costly and less effective than the SelectMDx strategy. The EPI provided the highest QALY with an incremental cost-effectiveness ratio of $58,404 per QALY. The use of biomarkers could reduce the number of unnecessary biopsies by 24% to 34% compared to the current standard of care.

CONCLUSIONS

Applying biomarkers in men with elevated prostate specific antigen to determine the need for biopsy improved quality adjusted survival by decreasing the number of biopsies performed and the treatment of indolent disease. Using SelectMDx or the EPI following elevated prostate specific antigen but before proceeding to biopsy is a cost-effective strategy in this setting.

Finasteride does not prevent bladder cancer: A secondary analysis of the Medical Therapy for Prostatic Symptoms Study

BACKGROUND

Preclinical models have demonstrated that androgen receptor modulation can influence bladder carcinogenesis with an inverse association observed between serum androgen levels and bladder cancer (BC) incidence. It is still unclear whether 5α-reductase inhibitors, by preventing the conversion of testosterone to dihydrotestosterone, have a similar effect. This study aims to evaluate whether dihydrotestosterone-mediated androgen activity has an impact on BC incidence in a cohort of men included in a clinical trial of finasteride vs. placebo with rigorous compliance monitoring.

METHODS

A secondary analysis was performed on all patients enrolled in the Medical Therapy for Prostatic Symptoms (MTOPS) Study and included in the biopsy substudy. Men were stratified into groups based on receiving finasteride and the incidence of BC compared between the groups.

RESULTS

After exclusions for poor finasteride compliance (n = 338) and missing serum hormone results (n = 9), 2,700 men were eligible for analysis. In total, 0.8% (n = 18) of the cohort was diagnosed with BC during the trial period. There was no difference in the incidence of BC between men who received finasteride and those who did not (0.74% [n = 9] vs. 0.61% [n = 9], P = 0.67). Neither serum testosterone levels, prostate cancer diagnosis nor urinary bother (measured by International Prostate Symptom Score) demonstrated an association with BC diagnosis. These relationships were consistent in the subgroup of men in the biopsy substudy.

CONCLUSION

There was no observable relationship between decreased dihydrotestosterone levels and BC diagnosis.

An objective measurement of urinary continence recovery with pelvic floor physiotherapy following robotic assisted radical prostatectomy

Background

To assess the impact of structured pelvic floor physiotherapy including repeated standardized measurements in regaining urinary continence in those men who have undergone a robotic-assisted laparoscopic radical prostatectomy (RALP).

Methods

A retrospective database was created on men who had undergone a RALP while under the care of two senior urological surgeons between January 2013 and July 2016 and then took part in a formal pelvic floor rehabilitation program were included in the study. Men were initially seen pre-operatively and then after removal of their indwelling catheter commenced their structured continence program. They were instructed to record their pad weights commencing at week four post-RALP. For each subsequent week, an average of the 24-hour urine leakage was recorded and compared to their first recorded week (baseline) to assess improvement of urinary continence over time.

Results

Forty-five men with a median age of 63.7 years were followed up for a mean of 11.3 weeks post-operatively. The mean daily urine leakage during the first recorded week was 408.0 mL. This decreased to 205.8 and 110.1 mL at 2 and 3 months post-RALP (P<0.05). This equated to a significant 57.1% (95% CI, 52.9% to 61.3%) and 75.6% (95% CI, 72.3% to 78.8%) improvement in urinary leakage at the same respective time points.

Conclusions

There is considerable improvement of urinary leakage following RALP in the short-term in men who participated in a structured, physiotherapist-led pelvic floor re-training program.

Updates of prostate cancer staging: Prostate-specific membrane antigen

The ability to accurately stage prostate cancer in both the primary and secondary staging setting can have a major impact on management. Until recently radiological staging has relied on computer tomography, magnetic resonance imaging, and nuclear bone scans to evaluate the extent of disease. However, the utility of these imaging technologies has been limited by their sensitivity and specificity especially in detecting early recurrence. Functional imaging using positron-emission tomography with a radiolabeled ligand targeted to prostate-specific membrane antigen has transformed the prostate cancer imaging landscape. Initial results suggest that it is a substantial improvement over conventional imaging in the setting of recurrence following primary therapy by having a superior ability to detect disease and to do so at an earlier stage. Additionally, it appears that the benefits seen in the secondary staging setting may also exist in the primary staging setting.