Using simulation modeling, researchers found that prostate-specific antigen (PSA) screening can be cost-effective if men with low-risk prostate cancer do not undergo treatment and if clinicians use restrictive criteria to make a decision to biopsy. The new study, which also shows that once diagnosed, a conservative management of low-risk prostate cancer is necessary for cost-effectiveness, is published in JAMA Oncology.
“Our findings have clear implications for the future of PSA screening in the United States,” wrote Ruth Etzioni, PhD, of the Fred Hutchinson Cancer Research Center in Seattle, and coauthors. “Rather than stopping PSA screening, as recommended by the US Preventive Services Task Force, implementation of strategies that extend the screening interval and/or use higher PSA biopsy thresholds have the potential to preserve substantial benefit while controlling harm and costs.”
The researchers created 18 screening strategies that varied by the age at which PSA screening started and ceased, by timing of screening, biopsy referral factors, and treatment approach. These strategies were then tested on simulated cohorts of men aged 40 and older.
Cost of the 18 strategies ranged from $263 to $1,371 per individual. Per life-year, costs ranged from $7,335 to $21,649. Each strategy increased life-years of the simulated population.
The cost-effective scenarios, the authors found, were ones that incorporated selective treatment plans in which low-risk disease, defined as a Gleason score of lower than 7 and clinical T2a stage or lower, are treated only after clinical progression of the disease. In other words, scenarios that incorporated active surveillance were found to be cost-effective. These approaches increased quality-adjusted life-years (QALYs) and were cost-effective.
Scenarios that incorporated a contemporary treatment based on age, cancer stage, and grade used by the Surveillance, Epidemiology, and End Results (SEER) program from 2010—whereby men with low-risk disease are treated—increased QALYs only when PSA levels higher than 10.0 ng/mL or age-dependent thresholds triggered a biopsy referral. For these scenarios, only those that incorporated an every 4-year schedule for men between the ages of 55 and 69 were cost-effective.
While at least one prior study has shown that PSA screening does indeed decrease mortality from prostate cancer, the currently relevant question is whether screening does more harm than good, wrote Andrew J. Wickers, PhD, a biostatistician at Memorial Sloan Kettering Cancer Center and professor of public health at Weill Cornell Medical College in New York, in an accompanying commentary. The decision to screen is complex as the results of the test are tied to decisions to biopsy and treat prostate cancer, once detected. “The study,” wrote Wickers, “forces us to change the debate from ‘Should we screen?’ to ‘How can we get physicians to follow best practice?’”