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PSA testing cost-effective when used conservatively
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Less frequent PSA screening and more restrictive criteria for biopsy coupled with selective treatment strategies increased the chances PSA screening would be cost-effective, according to the results of a modeling study.
The use of PSA screening to detect prostate cancer is controversial, particularly in the wake of a recommendation against its routine use issued by the U.S. Preventive Services Task Force in 2011. Although experts have recommended the use of personalized strategies for prostate cancer screening, these strategies are unlikely to be evaluated in randomized clinical trials, according to the researchers.
Joshua A. Roth
Joshua A. Roth, PhD, MHA, assistant member of Hutchinson Institute for Cancer Outcomes Research at Fred Hutchinson Cancer Research Center and affiliate assistant professor at University of Washington, and colleagues sought to determine the cost-effectiveness of PSA screening, particularly in combination with the increased use of conservative management outcomes for low-risk, screen-detected cases.
Roth and colleagues designed a microsimulation model of prostate cancer incidence and mortality, which simulated a cohort of men in the United States undergoing 18 PSA screening strategies beginning at age 40 years.
The model included two initial treatment scenarios, categorized as contemporary or selective treatment practices. Under contemporary screening practices, men diagnosed with prostate cancer underwent curative treatment — prostatectomy or radiotherapy, with or without androgen deprivation therapy — based on the frequencies observed in the SEER program by age, cancer stage and grade in 2010.
Under selective therapy, men with lower Gleason scores (< 7) and clinical stage cancer ( T2a) would only receive treatment after clinical progression. All other cases underwent contemporary treatment practices.
Key study endpoints included life-years (LY), quality-adjusted life-years (QALY), direct medical expenditures, and cost per LY and QALY gained. Researchers evaluated cost-effectiveness as willingness-to-pay thresholds ranging from $50,000 to $150,000 per QALY.
When compared with no screening, all screening strategies increased LYs (range, 0.03-0.06) and costs (range, $263-$1,371). Costs ranged from $7,335 to $21,649 per LY gained.
When using contemporary treatment practices, only screening strategies that used a biopsy referral threshold at a PSA higher than 10 ng/mL increased QALYs (range, 0.002-0.004), with costs ranging from $11,977 to $21,649 per LY in this subset. Further, only quadrennial screening of men aged 55 years to 69 years with a biopsy threshold higher than 10 ng/mL was cost-effective ($92,446 per QALY).
Although all selective treatment strategies increased costs (range, $263-$703), all corresponded with increased QALYs (range, 0.002-0.004).
Three screening strategies compared most favorably with no screening in the selective treatment model. The first used a 4-year screening interval and PSA biopsy threshold of 4 ng/mL and yielded a cost-effectiveness ratio of $8,622 per LY gained and $89,333 per QALY gained.
The second and third used a PSA biopsy threshold of 4 ng/mL. The second used a screening interval of 2 years, with cost-effectiveness ratios of $8,600 per LY gained and $120,952 per QALY gained. The third used a 4-year screening interval and yielded a cost-effectiveness ratio of $7,355 per LY gained and $70,831 per QALY gained.
The researchers acknowledged that a microsimulation model cannot fully compare with head-to-head evaluations of screening strategies in the real-world setting.
Further, they noted that the selective treatment strategies included in the model may underestimate survival and costs compared with contemporary active surveillance protocols.
“Our work adds to the growing consensus that highly conservative use of the PSA test and biopsy referral is necessary if PSA screening is to be cost-effective,” Roth and colleagues wrote. “Among the strategies considered, less frequent screening and more restrictive criteria for biopsy resulted in greater chances of PSA screening being cost-effective — particularly when combined with selective treatment strategies that do not immediately treat low-risk, screen-detected cases.”
Screening practices that can be adapted and refined over time can be made more effective, Andrew J. Vickers, PhD, attending research methodologist at Memorial Sloan Kettering Cancer Center, wrote in an accompanying editorial.
“Roth [and colleagues] clearly demonstrate that if we follow the literature on how to screen with PSA, and which screen-detected prostate cancers to treat, we will likely do more good than harm,” Vickers wrote. “If we simply carry on with common practice — screening older men, aggressively treating low-risk disease — then we should call for PSA screening to end.” – by Cameron Kelsall
Disclosure: The researchers report no relevant financial disclosures. Vickers reports that he is named on a patent application for a prostate cancer detection model licensed to OPKO Health Inc., for which he is entitled to royalties. He further reports holding stock options with OPKO Health Inc.
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