The introduction of prostate-specific antigen (PSA) testing for use in the early detection of prostate cancer has led to controversy regarding the appropriateness of prostate cancer screening and any subsequent treatment. This controversy is due, in part, to the fact that the effect of early treatment of prostate cancer on mortality is not yet known. However, other cancer screening programs such as breast and cervical cancer were implemented without such knowledge. In fact, proof of the efficacy of these other screening programs was based on their widespread use in the community and not on controlled, randomized trials. One critical difference between these other cancer screening programs and prostate cancer screening is that prostate cancer screening became available when cost control was a dominant concern in the health-care system. The rising cost of health care has made payors (employers, insurance companies, and federal and state governments) less willing to approve new benefits for their members.
The etiology of the current cost consciousness in health care is well known. American companies are now forced to compete globally. The relatively high price of health care for American businesses has decreased productivity and hampered their ability to compete internationally. Rising costs of health care have also placed a burden on federal and state governments. Ever increasing budget deficits and the contribution of Medicaid and Medicare to these deficits have compelled governments to better control their health-care costs.
Regardless of the present healthcare environment, the cost of care must always be considered; very few interventions in medicine, however, offer actual cost savings. Most add cost while hopefully providing a reasonable benefit to patients. Supplying endless cost- effective interventions could conceivably bankrupt our government and businesses.
Patients, whether they are young or old, curable or incurable, afflicted with cancer or benign disease, have always competed for health-care resources. In todays health-care environment, they are competing for more limited resources as cost control efforts intensify.
Currently, proof of efficacy and cost-effectiveness are central requirements for the implementation of new medical interventions. Practitioners must decide whether the dollars spent on a new intervention, such as prostate cancer screening, are worth the benefits (defined in terms of years of life saved, improved quality of life, or discomfort avoided) compared to alternative uses of the same dollars on more established interventions. The costs and benefits of prostate cancer screening and subsequent treatment can be definitively determined only by controlled, randomized trials with long-term follow up. Until such studies become available, doctors and patients must make decisions regarding the appropriateness of prostate cancer screening based on the currently available evidence.
From strictly a financial perspective, the most cost-effective method of treating prostate cancer is probably not to treat it at all. Treatment of a disease usually costs more than no treatment. However, to let men die of prostate cancer or even to let prostate cancer progress locally without intervention would be morally unacceptable in this country. While the United States is certainly willing to commit some portion of its health-care resources to the treatment of prostate cancer, the level of such commitment is not known. The proportion of total health-care resources to be spent on treating prostate cancer is not merely an economic decision, but a social and ethical one as well. The controversy surrounding the expense of prostate cancer treatment is not due to the costs of treating prostate cancer detected by traditional methods (biopsy performed due to local symptoms, palpable nodule on digital rectal examination [DRE], or bone pain), but rather to the higher costs incurred from the widespread use of PSA screening. Society must decide whether this additional outlay of health-care resources is worthwhile. This decision will be based, in part, on the magnitude of these additional costs and the benefits they produce for patients.
Any discussion of the increased costs of prostate cancer due to PSA screening must address the issue of clinically insignificant prostate cancer. The incidence of prostate cancer has increased markedly with the introduction of PSA. If this increased incidence is due to the detection of a larger number of clinically insignificant prostate cancers, the cost of treatment will rise, with little benefit in terms of increased survival and with some increase in morbidity and mortality due to that treatment. This would not represent a wise use of health-care resources.
Several studies indicate that concern regarding increased incidental prostate cancer detection from PSA screening is unfounded.[1,2] By the strict pathologic criteria currently available, prostate cancer screening with PSA does not result in the diagnosis of a larger proportion of clinically insignificant cancers than were diagnosed by traditional methods of detection (biopsy performed due to local symptoms, abnormal DRE, or symptoms of metastatic disease). Much of the recent increase in the number of prostate cancer cases is due to the detection of prevalence cancers. These are cancers that would have been diagnosed in later years by traditional methods, but are being caught earlier due to PSA screening. Once these prevalence cancers have been removed from the population by prostate cancer screening, the incidence of prostate cancer detection should return to approximate historical levels.
Widespread use of PSA screening will certainly increase health-care costs. The cost of a serum PSA (with or without the cost of a DRE) will be incurred for all men screened. The use of PSA will also lead to a portion of screened men undergoing a transrectal ultrasound (TRUS) and prostate biopsy. These costs must also be attributed to screening. However, even without PSA screening, a significant number of these men would still undergo PSA testing and subsequent TRUS and prostate biopsy due to local symptoms or an abnormal DRE.
Several investigators have developed models to calculate the additional costs to the health-care system due to screening. Optenberg and Thompson estimated that the cost resulting from the first year of screening men ages 50 to 70 years, would be $27.9 billion. They compared this to the $255 million currently spent for prostate cancer treatment for men in this age range. Kramer et al estimated that the total cost of the first year of prostate cancer screening with PSA for men ages 50 to 74 would be $11.9 billion. These estimates include the costs of screening, diagnosis, treatment, and complications resulting from such treatment.
These types of analyses can potentially lead to a gross overestimation of the costs of screening. First, not all men 50 to 70 years old will be eligible for screening due to various comorbidities that will decrease their life expectancy to less than 10 to 15 years. Second, not all men will submit to the screening examination. Virtually every medical group recommends serial mammography for women over age 50 and this recommendation has received widespread publicity for many years. Yet, fewer than 50% of eligible women have a mammogram on a yearly basis. Furthermore, one-third of men who volunteered for PSA screening as part of a research protocol and subsequently had a suspicious examination refused further evaluation.[1,7] It seems likely that only a minority of eligible men would undergo PSA screening, and then only a portion of those men would pursue further evaluation if indicated. Since the costs of screening and diagnosis represent only approximately 10% of the total costs resulting from prostate cancer screening (the remaining costs come from subsequent treatment of the prostate cancers detected), it is unlikely that these increased costs alone will significantly increase overall health-care costs.
However, treatment resulting from prostate cancer screening with PSA will increase overall health-care costs. This increase will not be due to the detection of clinically insignificant prostate cancer. The majority of prostate cancers detected as a result of PSA screening are clinically significant, and therefore would have eventually required treatment (provided screening is done in men with more than 10 years of life expectancy).[1,7] Prostate-specific antigen screening will diagnose cancers earlier than traditional methods of prostate cancer detection, and this early detection will increase health- care costs by two factors: cost discounting and stage migration.