Comparative Cost-Effectiveness of Prostate-Specific Membrane Antigen Positron Emission Tomography Agents and Conventional Imaging for Initial Diagnosis of Prostate Cancer in the United States

Background: Molecular imaging with prostate-specific membrane antigen (PSMA)-targeted positron emission tomography (PET) radiotracers is more sensitive and specific than conventional imaging (CI) for both primary staging of prostate cancer and identifying biochemical recurrence.A recent cost-effectiveness analysis found that the PSMA PET tracer piflufolastat F 18 was more cost-effective compared to fluciclovine F-18, gallium68-PSMA-11 (PSMA 11), and CI (bone scans, computed tomography, and magnetic resonance imaging) for the diagnosis and staging of prostate cancer from a United States healthcare system perspective.With the 2023 approval of flotufolastat F 18 as a new PSMA PET tracer, we have updated the model to also assess its economic value.Objective: The aim of this study was to assess the cost-effectiveness of piflufolastat F 18 in comparison to flotufolastat F 18, PSMA 11, and CI for the staging of prostate cancer in patients with newly diagnosed local or regional prostate cancer.Methods: A hybrid economic model consisted of a decision tree to map out diagnosis and subsequent treatment, combined with a Markov model to predict the long-term outcomes of these treatment decisions, accounting for disease progression at initial imaging.Treatment pathways considered in the model included prostatectomy, radiation therapy, androgen deprivation therapy (ADT), radiotherapy + ADT, along with active surveillance.Model inputs were informed by data from clinical trials (OSPREY, CONDOR, LIGHTHOUSE), public data, and literature.Healthcare costs included diagnostic strategies, prostate cancer treatment, medical costs and adverse event (AE) management costs.Outcomes included life-years (LYs), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICERs).Results: Over a lifetime horizon, piflufolastat F 18 had the greatest effectiveness in terms of LYs (6.79) and QALYs (5.23); for the comparators, LYs ranged from 6.51 (flotufolastat F 18) and 6.50 (CI) to 6.75 (PSMA 11) while QALYs ranged from 4.93 and 4.92 to 5.19, respectively.Compared to flotufolastat F 18, PSMA 11, and CI, piflufolastat F 18 was more cost-effective, having respective ICERs of $762, $91,985, and $138,434 per incremental QALY.Among the included imaging modalities, piflufolastat F 18 demonstrated the greatest net monetary benefit ($588,702) using a willingness-to-pay threshold (WTP) of $150,000.The key drivers included cost of diagnostics, test sensitivity, and probability of cure given treatment.At this WTP threshold, the probability that piflufolastat F 18 is cost-effective was 100.0%, 78.4%, and 71.0% compared to flotufolastat F 18, PSMA 11, and CI, respectively.Conclusions: The findings of this analysis indicate that piflufolastat F 18 represents a cost-effective imaging modality for men with prostate cancer in the US.Compared with flotufolastat F 18, PSMA 11, and CI, piflufolastat F 18 was associated with higher projected LYs and QALYs, while generating a greater net monetary benefit.