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21st November 2022
A prostate cancer screening strategy that involves an MRI scan following a prostate specific antigen (PSA) test with subsequent targeted biopsies, is a more cost-effective strategy than using just a PSA and standard biopsy according to a cost-effectiveness analysis by Swedish researchers.
Prostate cancer (PCa) screening based on PSA, has been shown in a 16-year follow-up study, to reduce prostate cancer mortality. A biopsy is normally used to confirm the diagnosis of PCa though in recent years there has been an increase in the role of magnetic resonance imaging (MRI) as an alternative means for the identification of PCa. In fact, data suggests that the use of multi-parametric magnetic resonance imaging (MP-MRI) might allow 27% of patients to avoid a primary biopsy. In a 2021 study which compared MRI-targeted or standard biopsy for the purposes of screening for PCa, it was found that in men with a PSA level > 3 ng/ml, an MRI result suggestive of prostate cancer was non-inferior to standard biopsy for detecting clinically significant prostate cancer. In the trial, men were randomised to either a 10 to 12-core standard biopsy or to undergo a triage MRI and then a standard biopsy if the MRI results suggested prostate cancer. Given the non-inferior findings of this study, the Swedish team set out to determine the cost-effectiveness of the MRI-based screening approach in men aged 55 to 69 years of age.
The researchers modelled three scenarios: no screening (strategy 1); PSA and standard biopsy every four years (strategy 2) and finally, MRI following an elevated PSA and then a standard biopsy if the men had a PI-RADS value of between 3 and 5, i.e., which is suggestive of PCa. For each of the three strategies, the team modelled several different outcomes including the mean lifetime number of screening tests, MRIs, over-diagnosis (where screening was positive but would not have presented with symptoms before death due to other causes) and deaths. The incremental cost-effectiveness ratio (ICER), which represents the additional cost of one unit of outcome gained by one strategy compared with another, was calculated for each scenario. The ICER was calculated by dividing the difference in costs by the difference in quality-adjusted life-years (QALYs) for the no screening and the two alternative strategies.
Prostate cancer screening and cost-effectiveness
A total of 603 men were randomised to the standard arm and 929 to the MRI arm and of whom, 11.9% underwent MRI or any biopsy.
When compared against a strategy of no screening, the ICER for the MRI and combined biopsies was $53,736 per QALY gained compared to $69,254 for the PSA and standard biopsy strategy and which the authors designated as a moderate cost per QALY gain. Furthermore, MRI-based screening reduced the number of lifetime biopsies and over-diagnosis by approximately 50% and had a high probability of being cost-effective compared to the alternative strategies.
The authors concluded that a strategy for prostate cancer screening based on PSA followed by MRI with subsequent combined targeted and standard biopsies, had a high probability to be more cost-effective compared with the traditional screening pathway using PSA and a standard biopsy.
Hao S et al. Cost-effectiveness of Prostate Cancer Screening Using Magnetic Resonance Imaging or Standard Biopsy Based on the STHLM3-MRI Study. JAMA Oncol 2022
20th July 2021
Psoriatic arthritis (PsA) is a chronic, immune-mediated disease which affects around 22% of those with psoriasis. PsA can present as a combination of axial and peripheral disease with signs including arthritis, enthesitis, dactylitis as well as skin and nail changes. The disease can be treated with non-steroidal anti-inflammatory drugs, synthetic disease-modifying anti-rheumatic drugs but over recent years, there has been an increase in the use of biologic agents. The rational for the use of biologics, arises from evidence implicating a pathological role for the interleukin (IL)-12, and IL23 and IL-17 pathways in the disease. Ustekinumab is an IL-12/23 inhibitor and has been shown to give rise to significant and sustained improvements in the signs and symptoms of PsA. Equally, there is evidence that tumour necrosis factor (TNF) inhibitors are also an effective therapeutic modality, preventing radiographically observed progression of joint destruction in PsA. Nevertheless, an important consideration when deciding to use a biologic agent is which agent is most appropriate. This decision-making is hampered given the absence of head-to-head trials comparing ustekinumab with TNF inhibitors. In trying to compare the relative efficacy of these two treatments, a team from the University of Vienna, Austria, turned to data from the PsABio study. This international, prospective, observational, cohort study, is designed to evaluate the persistence, effectiveness and tolerability of ustekinumab verses TNF inhibitors in patients with PsA. All participants are followed-up biannually for 3 years with an initial analysis of outcomes after 6 months. The outcomes used are the clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA) and Minimal Disease Activity (MDA) or Very Low Disease Activity (VLDA). DAPSA, MDA and VLDA, are considered to be the most useful measures for the assessment of patients with PsA and are based on assessments of several measures including joint tenderness, swelling, and self-reported pain with higher scores reflecting more severe disease. Remission of disease has been defined by a cut-off score of less than 4. Participants were enrolled at 92 sites across Europe and the initial choice of treatment was made at the discretion of the patient’s rheumatologist. Data were collected, from the patient’s medical records, at baseline and then every 6 months.
A total of 868 patients (426 using ustekinumab) were included in the analysis. The mean age of ustekinumab participants was 51.2 years (43% male) whereas the TNF inhibitor participants were significantly younger (mean age 48.5 years, 45.7% male). In addition, disease duration was longer for those using ustekinumab (7.5 vs 6.2 years). Baseline cDAPSA scores were similar (31 vs 29.8, ustekinumab vs TNF inhibitors) and the improvement after 6 months was also similar (-13.7 vs -14.5). Furthermore, cDAPSA remission occurred in 17.5% vs 21.9% (ustekinumab vs TNF inhibitors).
In their discussion the authors commented on how their data clearly shows how both agents had a similar impact on PsA disease activity after only 6 months. They concluded by indicating that future publications will include a longer-term evaluation of the current data.
Smolen JS et al. Effectiveness of IL-12/23 inhibition (ustekinumab) versus tumour necrosis factor inhibition in psoriatic arthritis: observational PsABio study results. Ann Rheum Dis 2021