Cost-Effectiveness and Evidence Gaps Surrounding PSMA-PET for Recurrent Prostate Cancer Evaluation

TL;DR

This study evaluates whether PSMA-PET scans for recurrent prostate cancer are cost-effective in the US, finding potential benefits for some patients but highlighting the need for more data.

Contribution

The study introduces a decision-analytic model to assess PSMA-PET cost-effectiveness in biochemical recurrent prostate cancer, identifying evidence gaps.

Findings

PSMA-PET had an incremental cost-effectiveness ratio of $113,000/QALY in patients with lower PSA levels, suggesting potential cost-effectiveness.

High decision uncertainty was identified, indicating a need for additional data on diagnostic characteristics to reduce uncertainty.

Up-front PSMA-PET was associated with higher costs and QALYs compared to CTBS, but exceeded the $150,000/QALY willingness-to-pay threshold in general cases.

Abstract

This economic evaluation estimates health and cost outcomes and cost-effectiveness associated with use of prostate-specific membrane antigen positron emission tomography (PSMA-PET) for evaluating biochemical recurrent prostate cancer.

Is the use of prostate-specific membrane antigen (PSMA) positron emission tomography (PET) for the evaluation of biochemical recurrent (BCR) prostate cancer cost-effective in the US?

This economic evaluation of modeled patients with prostate cancer found that PSMA-PET had an incremental cost-effectiveness ratio below the willingness-to-pay threshold in patients with BCR and lower prostate-specific antigen levels. However, the decision-analytic model indicated high decision uncertainty and identified that additional data on diagnostic characteristics may be associated with reduction of this uncertainty.

This study found that PSMA-PET has the potential to be cost-effective for selected patients with recurrent prostate cancer, but additional evidence is needed to reduce uncertainty about its value across clinical scenarios.

Prostate-specific membrane antigen positron emission tomography (PSMA-PET), a form of molecular imaging, increases detection of advanced and metastatic prostate cancer, but its potential to increase treatment costs due to increased detection is poorly defined.

To estimate lifetime health and cost outcomes and evaluate the cost-effectiveness associated with implementing PSMA-PET in the clinical evaluation of a patient with a biochemical recurrence (BCR) of prostate cancer, with evaluation of sources of uncertainty in the underlying evidence and assessment of the need and focus of additional data collection.

This economic evaluation developed a decision-analytic model consisting of a decision tree and a Markov model informed by published literature and a study of patients with BCR prostate cancer undergoing PSMA-PET after definitive surgery or radiation therapy at 2 high-volume US academic centers. The analysis was performed between August 1, 2024, and May 1, 2025.

Patients underwent (1) PSMA-PET, (2) PSMA-PET imaging as a reflex test if computed tomography plus bone scan (CTBS) was negative or equivocal (CTBS + PSMA-PET), and (3) CTBS alone.

Lifetime quality-adjusted life-years (QALYs) and costs, incremental cost-effectiveness ratio (ICER), and value of information estimates were assessed, with 95% uncertainty intervals (UIs). We assumed a willingness-to-pay threshold of $150 000 per QALY.

The model simulated 1000 patients with BCR (median age, 66 years) and estimated that up-front PSMA-PET is expected to have the highest mean QALYs (7.12 QALYs [95% UI, 6.71-7.51 QALYs]) compared with 6.55 QALYs (95% UI, 6.08-7.03 QALYs) for CTBS; it was also estimated to have higher mean costs ($451 000 [95% UI, $336 000-$577 000]) compared with $351 000 (95% UI, $263 000-$455 000]) for CTBS; consequently, PSMA-PET had mean increments of $99 000 (95% UI, $55 000-153,000) in costs and 0.58 QALYs (95% UI, 0.35-0.82 QALYs) compared with CTBS, leading to an ICER of $172 000 per QALY, which exceeded the assumed $150 000/QALY willingness-to-pay threshold. In patients with lower prostate-specific antigen levels (<2 ng/mL), PSMA had mean increments of $61 000 (95% UI, $21 000-$104 000) in costs and 0.54 QALYs (95% UI, 0.34-0.77 QALYs) compared with CTBS, leading to an ICER of $113 000/QALY, suggesting it had the potential to be cost-effective. Because of high decisional uncertainty, additional information regarding outcomes and diagnostic characteristics may be associated with reduced uncertainty and a gain of 15 747 QALYs.

This study found that PSMA-PET may be associated with improved disease detection but may not be cost-effective due to high treatment costs offsetting moderate improvements in QALYs. Further research is needed to identify patient subsets and clinical scenarios in which molecular imaging provides the greatest value.

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