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Cost outweighed benefit of PSA screening among older men
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Prostate cancer screening demonstrated little benefit for men aged at least 75 years, but the Medicare fee-for-service program spent $145 million annually on PSA-based screenings for this age group, according to study results.
Despite increasing concerns about routine PSA screening in older adults — including a US Preventive Services Task Force (USPSTF) recommendation that men aged ≥75 and older should not undergo routine PSA tests — little information exists about the economic impact of screening, according to Xiaomei Ma, PhD, associate professor at Yale School of Public Health, and colleagues.
“The USPSTF assessments did not take into account the cost of screening, and Medicare continues to reimburse for the test,” Ma and colleagues wrote.
Ma and colleagues conducted a retrospective cohort study of 99,652 male Medicare beneficiaries aged 66 to 99 years who had never been diagnosed with prostate cancer or other lower urinary tract symptoms as of Dec. 31, 2006.
Participants were followed for 3 years to evaluate the cost of PSA screening and downstream procedures, including biopsy, pathologic analysis and hospitalization due to biopsy complications, at both the national and the hospital referral region level.
Approximately 51.2% of men received PSA screening tests during the 3-year period, and 2.9% underwent biopsy. During the study period, the national fee-for-service Medicare program spent $447 million annually on PSA-based screenings.
Researchers observed that the costs of prostate cancer screening varied considerably. The mean annual screening cost at the hospital referral region level ranged from $17 to $62 per beneficiary. Variation was attributed to disparities in the costs of the follow-up tests across regions rather than the cost of PSA tests.
Cary Gross
Biopsy-related procedures accounted for 72% of the overall screening costs. In addition, men who lived in the highest hospital referral region quartile for screening expenditures were significantly more likely to be diagnosed with prostate cancer of any stage (incidence rate ratio=1.2; 95% CI, 1.07-1.35) and localized cancer (incidence rate ratio=1.3, 95% CI, 1.15-1.47) than those who lived in hospital referral regions in the lowest quartile.
“In terms of what these results mean for Medicare spending, this is just the tip of the iceberg,” Cary Gross, MD, professor of internal medicine at Yale School of Medicine and director of the Yale COPPER Center, said in a press release. “Many older men who are diagnosed with early-stage prostate cancer may end up receiving therapy that is potentially toxic, has little chance of benefit, and carries substantial cost. In order to truly understand the costs of screening, the next step is to identify how many additional cancers are being diagnosed and treated as a result of screening older men for prostate cancer. We need better tools to target screening efforts toward those who are likely to benefit.”
Disclosure: The researchers report no relevant financial disclosures.Perspective
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Peter E. Clark, MD
Ma and colleagues recently published a study in the journal Cancer that examined the cost implications of PSA screening in a Medicare population. Using administrative data available through the SEER-Medicare Linked database, this thoughtful analysis addressed an important knowledge gap in our understanding of the controversies surrounding the role of PSA screening in the United States: How much is it costing us to diagnose prostate cancer?
The authors made several important observations. The total annual cost for screening and diagnosing prostate cancer was $447 million, and the majority of that cost was due to the costs of the biopsy rather than the PSA test itself. Importantly, there was also notable regional variation in the costs of PSA screening, primarily driven by variations in the biopsy rates. This offers a significant quality improvement opportunity to analyze the drivers of this variation and perhaps establish better national guidelines on indications for biopsy and the adherence to such guidelines. Another potential quality improvement was the finding that a substantial cost was associated with PSA screening in men older than 75 years, a routine practice not supported by any of the existing guidelines.
Several important limitations of this study should be acknowledged. Perhaps the most important is that, because this is a Medicare-linked data set, it only reflects the costs associated with men older than 65 years. Because the focus of PSA screening is typically directed largely at younger men, this is an important caveat. In addition, there is a complex and controversial interrelationship between PSA screening and a reduction in the rates of advanced disease at diagnosis and lower prostate cancer mortality. This study does not address the potential cost savings created by PSA screening in reducing the expenses associated with treating men with advanced/metastatic prostate cancer. Such a study will be very difficult to address but is an important consideration in the ongoing debate surrounding PSA screening in this country.
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