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期刊来源：Ann Intern Med

原文链接：https://doi.org/10.7326/M23-1504

摘要内容如下：

背景

当代前列腺癌（PCA）筛查使用一线前列腺特异性抗原（PSA）检测，随后可能对PSA水平升高的男性进行多参数磁共振成像（MPMRI）。一线双参数MRI（BPMRI）筛查已被提议作为一种替代方法。

客观

评估一线BPMRI与基于PSA的筛查的比较有效性和成本效益。

设计

使用微观模拟模型进行决策分析。

数据源

监测、流行病学和最终结果数据库；随机试验。

目标人群

既往无筛查或前列腺癌诊断的55岁美国男性。

时间范围

一生。

透视

美国医疗保健系统。

干预

每两年筛查一次至69岁，使用一线PSA检测（检测阳性阈值，4µg/L），使用或不使用二线MPMRI或一线BPMRI（检测阳性阈值，PI-RADS[前列腺成像报告和数据系统]3至5或4至5），然后在MRI或MRI加经直肠超声引导下进行活检。

结果测量

筛查测试、活检、诊断、过度诊断、治疗、前列腺癌死亡、质量调整和未调整的生命年节省以及成本。

基础案例分析结果

对于1000名男性，一线BPMRI与一线PSA检测相比，预防了2至3例前列腺癌死亡，增加了10至30个生命年（每人4至11天），但根据活检成像方案，活检数量增加了1506至4174，过度诊断数量增加了38至124。在传统的成本效益阈值下，用MPMRI进行一线PSA检测，然后对PI-RADS 4至5进行活检，产生了最大的净货币效益。

敏感性分析结果

一线PSA检测仍然更具成本效益，即使BPMRI是免费的，所有患有低风险前列腺癌的男性都接受了监测，或者每四年进行一次筛查。

局限性

一线BPMRI的性能基于二线MPMRI数据。

结论

决策分析表明，PCA筛查的相对有效性和成本效益是由假阳性结果和过度诊断驱动的，MPMRI的一线PSA检测优于一线BPMRI。

主要资金来源

国家癌症研究所。

英文原文如下：

Abstracts

BACKGROUND  Contemporary prostate cancer (PCa) screening uses first-line prostate-specific antigen (PSA) testing, possibly followed by multiparametric magnetic resonance imaging (mpMRI) for men with elevated PSA levels. First-line biparametric MRI (bpMRI) screening has been proposed as an alternative.

OBJECTIVE  To evaluate the comparative effectiveness and cost-effectiveness of first-line bpMRI versus PSA-based screening.

DESIGN  Decision analysis using a microsimulation model.

DATA SOURCES  Surveillance, Epidemiology, and End Results database; randomized trials.

TARGET POPULATION  U.S. men aged 55 years with no prior screening or PCa diagnosis.

TIME HORIZON  Lifetime.

PERSPECTIVE  U.S. health care system.

INTERVENTION  Biennial screening to age 69 years using first-line PSA testing (test-positive threshold, 4 µg/L) with or without second-line mpMRI or first-line bpMRI (test-positive threshold, PI-RADS [Prostate Imaging Reporting and Data System] 3 to 5 or 4 to 5), followed by biopsy guided by MRI or MRI plus transrectal ultrasonography.

OUTCOME MEASURES  Screening tests, biopsies, diagnoses, overdiagnoses, treatments, PCa deaths, quality-adjusted and unadjusted life-years saved, and costs.

RESULTS OF BASE-CASE ANALYSIS  For 1000 men, first-line bpMRI versus first-line PSA testing prevented 2 to 3 PCa deaths and added 10 to 30 life-years (4 to 11 days per person) but increased the number of biopsies by 1506 to 4174 and the number of overdiagnoses by 38 to 124 depending on the biopsy imaging scheme. At conventional cost-effectiveness thresholds, first-line PSA testing with mpMRI followed by either biopsy approach for PI-RADS 4 to 5 produced the greatest net monetary benefits.

RESULTS OF SENSITIVITY ANALYSIS  First-line PSA testing remained more cost-effective even if bpMRI was free, all men with low-risk PCa underwent surveillance, or screening was quadrennial.

LIMITATION  Performance of first-line bpMRI was based on second-line mpMRI data.

CONCLUSION  Decision analysis suggests that comparative effectiveness and cost-effectiveness of PCa screening are driven by false-positive results and overdiagnoses, favoring first-line PSA testing with mpMRI over first-line bpMRI.

PRIMARY FUNDING SOURCE  National Cancer Institute.

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