Cost-Effectiveness and Evidence Gaps Surrounding PSMA-PET for the Evaluation of Recurrent Prostate Cancer in the United States
Author(s)
Natalia Kunst, PhD1, Jessica Long, MPH2, Preston C. Sprenkle, MD2, Isaac Kim, MD2, Lawrence Saperstein, MD2, Maximilian Rabil, MD2, Umar Ghaffar, MD3, Jeffrey Karnes, MD3, Xiaomei Ma, PhD4, Cary P. Gross, MD2, Shiyi Wang, PhD4, Michael Leapman, MD2.
1Centre for Health Economics, University of York, York, United Kingdom, 2Yale School of Medicine, New Haven, CT, USA, 3Mayo Clinic, Rochester, MN, USA, 4Yale School of Public Health, New Haven, CT, USA.
1Centre for Health Economics, University of York, York, United Kingdom, 2Yale School of Medicine, New Haven, CT, USA, 3Mayo Clinic, Rochester, MN, USA, 4Yale School of Public Health, New Haven, CT, USA.
OBJECTIVES: Prostate-specific membrane antigen positron emission tomography (PSMA-PET) is a novel molecular imaging technology that has the potential to impact the evaluation and staging of prostate cancer. We aimed to evaluate long-term health and costs outcomes and cost-effectiveness of implementing PSMA-PET into US clinical practice for the evaluation of recurrent prostate cancer and identify the drivers of decision uncertainty.
METHODS: We developed a decision-analytic model that consisted of a decision tree and Markov model to simulate long-term health and cost outcomes of three imaging strategies: 1) immediate PSMA-PET imaging, 2) CT and bone scan (CTBS) followed by PSMA-PET if CTBS results are negative (CTBS+PSMA-PET), and 3) CTBS. Model input parameters and their probabilistic distributions were informed with a retrospective cohort study and published literature. Assuming a $100,000/QALY willingness-to-pay threshold and a US healthcare perspective, we evaluated the cost-effectiveness of the strategies considered by estimating incremental cost-effectiveness ratios (ICERs) for the population of interest (base-case analysis) and for patients stratified by prostate-specific antigen (PSA) levels (0-1.99, 2-4.99, ≥5 ng/mL). Finally, we identified the main drivers of decision uncertainty with value of information analysis.
RESULTS: In the base-case analysis, PSMA-PET led to the highest QALYs (7.12) but also higher costs ($546,000) compared to CTBS, resulting in $143,000/QALY ICER, which exceeded the assumed WTP threshold. CTBS+PSMA-PET was dominated. Analysis stratified by PSA level at the time of imaging indicated that PSMA-PET could be cost-effective for patients with the lowest PSA level (ICER $85,000/QALY) but not at higher PSA levels. Decision uncertainty was high, mainly driven by the diagnostic performance parameters.
CONCLUSIONS: This study indicates that PSMA-PET may be cost-effective for assessing recurrent prostate cancer in patients with low PSA level in the US. Our findings highlight high decision uncertainty and the potential need for additional data collection before implementing PSMA-PET into clinical practice.
METHODS: We developed a decision-analytic model that consisted of a decision tree and Markov model to simulate long-term health and cost outcomes of three imaging strategies: 1) immediate PSMA-PET imaging, 2) CT and bone scan (CTBS) followed by PSMA-PET if CTBS results are negative (CTBS+PSMA-PET), and 3) CTBS. Model input parameters and their probabilistic distributions were informed with a retrospective cohort study and published literature. Assuming a $100,000/QALY willingness-to-pay threshold and a US healthcare perspective, we evaluated the cost-effectiveness of the strategies considered by estimating incremental cost-effectiveness ratios (ICERs) for the population of interest (base-case analysis) and for patients stratified by prostate-specific antigen (PSA) levels (0-1.99, 2-4.99, ≥5 ng/mL). Finally, we identified the main drivers of decision uncertainty with value of information analysis.
RESULTS: In the base-case analysis, PSMA-PET led to the highest QALYs (7.12) but also higher costs ($546,000) compared to CTBS, resulting in $143,000/QALY ICER, which exceeded the assumed WTP threshold. CTBS+PSMA-PET was dominated. Analysis stratified by PSA level at the time of imaging indicated that PSMA-PET could be cost-effective for patients with the lowest PSA level (ICER $85,000/QALY) but not at higher PSA levels. Decision uncertainty was high, mainly driven by the diagnostic performance parameters.
CONCLUSIONS: This study indicates that PSMA-PET may be cost-effective for assessing recurrent prostate cancer in patients with low PSA level in the US. Our findings highlight high decision uncertainty and the potential need for additional data collection before implementing PSMA-PET into clinical practice.
Conference/Value in Health Info
2025-11, ISPOR Europe 2025, Glasgow, Scotland
Value in Health, Volume 28, Issue S2
Code
EE225
Topic
Clinical Outcomes, Economic Evaluation, Health Policy & Regulatory
Topic Subcategory
Value of Information
Disease
Oncology