Cost-effectiveness of the implementation of [68Ga]Ga-PSMA-11 PET/CT at initial prostate cancer staging

van der Sar, Esmée C. A.; Keusters, Willem R.; van Kalmthout, Ludwike W. M.; Braat, Arthur J. A. T.; de Keizer, Bart; Frederix, Geert W. J.; Kooistra, Anko; Lavalaye, Jules; Lam, Marnix G. E. H.; van Melick, Harm H. E.

doi:10.1186/s13244-022-01265-w

Insights into Imaging

Table 1 Decision table based on the diagnostic outcomes of the PEPPER-study cohort

From: Cost-effectiveness of the implementation of [⁶⁸Ga]Ga-PSMA-11 PET/CT at initial prostate cancer staging

Ground truth	Diagnosis	Patients (n)	Frequency (%)	SE (%)	ePLND spared (y/n)	Diagnostic scheme	Curative treatment scheme	Health state
[⁶⁸Ga]Ga-PSMA-11 PET/CT scenario
N0 patients
pN0	pN0	49	91%	-	No	GPP + MRI + ePLND	RT/RP	NEOD-N0
pN0	iN1_lim	5	9%	3.9%	Yes***	GPP + MRI	RT/RP + Pelvic RT + ADT	NEOD-N0
pN0	iN1_ext	0	NA*****	-	Yes**	NA	NA	NA
N1_Lim patients
pN1_lim	pN0	24	65%	7.8%	No*	GPP + MRI + ePLND	RT/RP + Pelvic RT + ADT	NEOD-N1
pN1_lim	iN1_lim	12	32%	-	Yes	GPP + MRI	RT/RP + Pelvic RT + ADT	NEOD-N1
pN1_lim	iN1_ext	1	2.7%	2.7%	Yes**	GPP + MRI	NA	False palliative
N1_Ext patients
pN1_ext	pN0	0	NA*****	-	No*	NA	NA	NA
pN1_ext	iN1_lim	1	33%	27.2%	Yes***	GPP + MRI	RT/RP + Pelvic RT + ADT	Palliative
pN1_ext	iN1_ext	2	67%	-	Yes	GPP + MRI	NA	Palliative
M1 patients
pM1	iM1	8	100%	-	Yes****	GPP + MRI	NA	Palliative
Standard of care scenario
N0 patients
pN0	pN0	54	100%	-	No	GPP + MRI + ePLND	RT/RP	NEOD-N0
N1_Lim Patients
pN1_lim	pN1_lim	37	100%	-	No	GPP + MRI + ePLND	RT/RP + Pelvic RT + ADT	NEOD-N1
N1_Ext patients
pN1_ext	pN1_ext	3	100%	-	No	GPP + MRI + ePLND	NA	Palliative
M1 Patients
pM1	pN0	8	100%	-	No	GPP + MRI + ePLND	RT/RP	Palliative

The proportion was used to define treatment costs and utilities. The patients distribution among states was used as cohort for the Markov simulation. ADT Androgen deprivation therapy, ePLND extended pelvic lymph node dissection, GPP = [⁶⁸Ga]Ga-PSMA-11 PET/CT, MRI magnetic resonance imaging, M1 distant metastasis including extra pelvic lymph node metastasis, bone and/or visceral metastasis, N0 no lymph node metastasis, N1lim limited lymph nodes metastasis defined as less than or equal to four pelvic lymph node metastasis, N1ext extended lymph nodes metastasis defined as more than four pelvic lymph node metastasis, NA not applicable, NEOD no evidence of disease, PET/CT positron emission tomography/computed tomography, PSMA prostate specific membrane antigen, RP radical prostatectomy, RT radiotherapy.
*ePLND would reveal misdiagnosis of the [⁶⁸Ga]Ga-PSMA-11 PET/CT and therefore assuring correct treatment
**Misdiagnosis by [⁶⁸Ga]Ga-PSMA-11 PET/CT would result in false positive palliative state and thus causing lower treatment effects
***Misdiagnosis by [⁶⁸Ga]Ga-PSMA-11 PET/CT would result higher treatment costs for pelvic radiotherapy and ADT but equal outcomes regarding after treatment effects
****ePLND would not recognize the M1 state resulting in higher treatment costs and lower treatment utilities for these patients in the standard of care. However after treatment effects would be equal
*****It was assumed to be impossible to overestimate more than 4 lymph nodes metastases in N0 patients and vice versa

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