SESAUA 2023: Review of Metastatic Disease Detection and Cost Analysis of Next Generation Imaging Use in Initial Staging of Prostate Cancer

( The 2023 SESAUA annual meeting included a prostate cancer session, featuring a presentation by Dr. Adonis Irons discussing the cost of next-generation imaging use in the initial staging of prostate cancer and reviewing metastatic disease detection. Next-generation imaging, such as Fluciclovine F18 (Axumin) and Gallium-68 PSMA use in PET, has had an increasing role in prostate cancer staging given growing evidence of increased detection of metastases.

However, there is a discrepancy in guidelines for offering this with the AUA still recommending prerequisite bone scan and CT or MRI in high-risk disease staging (whereas the NCCN guidelines do not require previous conventional imaging), despite noted increased sensitivity/specificity of next-generation imaging. Missed metastases affect both patient outcomes and financial aspects of management. To add to the understanding of next-generation imaging’s impact, Dr. Irons and colleagues evaluated staging outcomes and imaging costs between next-generation imaging and conventional imaging at a local healthcare level.

Charts of patients diagnosed with unfavorable intermediate-risk or higher prostate cancer were retrospectively reviewed to compare findings of metastatic disease on staging imaging. Patients were included if they had (i) either Axumin or PSMA PET, and (ii) at least one form of conventional imaging (CT abdomen/pelvis with contrast and/or bone scan) within <12 months of next-generation imaging. Charged costs from imaging centers for each modality were used to calculate the relative costs of the study population:

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The average cost of next-generation imaging was compared to the assumed costs of each patient having a complete conventional workup, per AUA guidelines.

This analysis included 6 men with high-risk disease and 22 with unfavorable intermediate-risk. Overall, 21.4% of men had next-generation imaging positive for metastases with negative conventional imaging, with half of those upstaged having high-risk disease. The lowest PSA level for an upstaged patient was 8.17 ng/mL. The average cost of the two next-generation imaging types totaled $11,705, although PSMA cost ($9,409) was slightly lower than the combined cost of CT/bone scan ($9,825). Relative costs of all imaging if CT, bone scan, and next-generation imaging were completed totaled $602,840, or $21,530 per patient. The estimated cost of upfront next-generation imaging staging totaled $327,740, with projected savings of $275,100 for this study population:

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Dr. Irons concluded his presentation by discussing the cost of next-generation imaging use in the initial staging of prostate cancer and reviewing metastatic disease detection with the following take-home messages:

  • This study reports metastatic disease detection rates similar to that of current literature with comparable costs in a small-scale analysis to highlight the benefits of next-generation imaging
  • Although further research is needed to assess long-term disease outcomes and fiscal impacts on the healthcare system, this study adds to a foundation of evidence showing the benefits of phasing out conventional imaging and utilizing next-generation imaging in appropriately selected patients

Presented by: Adonis Irons, MD, University of Tennessee Health Science Center, Memphis, TN

Co-Authors: Christian Dewan, MD, William Fry, MD, Anthony Patterson, MD, Christopher Ledbetter MD, Robert Wake MD.

Affiliations: University of Tennessee Health Science Center, Memphis, TN

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2023 Southeastern Section of the American Urological Association (SESAUA) Annual Meeting, Amelia Island, FL, Wed, Mar 15 – Sat, Mar 18, 2023.