Economic Analysis of Prostate-Specific Antigen Screening and Selective Treatment Strategies

Abstract

Importance: Prostate-specific antigen (PSA) screening for prostate cancer is controversial. Experts have suggested more personalized or more conservative strategies to improve benefit-risk tradeoffs, but the value of these strategies-particularly when combined with increased conservative management for low-risk cases-is uncertain.

Objectives: To evaluate the potential cost-effectiveness of plausible PSA screening strategies and to assess the value added by increased use of conservative management among low-risk, screen-detected cases.

Design, setting, and participants: A microsimulation model of prostate cancer incidence and mortality was created. A simulated contemporary cohort of US men beginning at 40 years of age underwent 18 strategies for PSA screening. Treatment strategies included (1) contemporary treatment practices based on age and cancer stage and grade observed in the Surveillance, Epidemiology, and End Results program in 2010 or (2) selective treatment practices whereby cases with a Gleason score lower than 7 and clinical T2a stage cancer or lower are treated only after clinical progression, and all other cases undergo contemporary treatment practices. National and trial data on PSA growth, screening and biopsy patterns, incidence of prostate cancer, treatment distributions, treatment efficacy, mortality, health-related quality of life, and direct medical expenditure were analyzed. Data were collected from March 18, 2009, to August 15, 2014, and analyzed from November 20, 2012, to December 11, 2015.

Interventions: Eighteen screening strategies that vary by start and stop age, screening interval, and criteria for biopsy referral and contemporary or selective treatment practices.

Main outcomes and measures: Life-years (LYs), quality-adjusted life-years (QALYs), direct medical expenditure, and cost per LY and QALY gained.

Results: All 18 screening strategies were associated with increased LYs (range, 0.03-0.06) and costs ($263-$1371) compared with no screening, with the cost ranging from $7335 to $21 649 per LY. With contemporary treatment, only strategies with biopsy referral for PSA levels higher than 10.0 ng/mL or age-dependent thresholds were associated with increased QALYs (0.002-0.004), and only quadrennial screening of patients aged 55 to 69 years was potentially cost-effective in terms of cost per QALY (incremental cost-effectiveness ratio, $92 446). With selective treatment, all strategies were associated with increased QALYs (0.002-0.004), and several strategies were potentially cost-effective in terms of cost per QALY (incremental cost-effectiveness ratio, $70 831-$136 332).

Conclusions and relevance: For PSA screening to be cost-effective, it needs to be used conservatively and ideally in combination with a conservative management approach for low-risk disease.

Figure 1. Candidate PSA screening strategies

Strategies were suggested by published screening studies, approximation to a trial protocol, approximation to a clinical recommendation statement from a national organization, or a combination of sources. All strategies are compared to no screening. NCCN=National Comprehensive Cancer Network ERSPC=European Randomized Study of Screening for Prostate Cancer AUA=American Urological Association PSA¹-dependent screening interval is every 1 year if PSA >3.0 µg/L and every 2 years otherwise. PSA²-dependent screening interval is every 2 years if PSA >1.0 µg/L and every 4 years otherwise. Age¹-dependent PSA thresholds for biopsy referral are 3.5, 4.5, and 6.5 µg/L for ages 50–59, 60–69, and 70–74 y. Age²-dependent PSA thresholds for biopsy referral are 4.5, 5.5, and 8.5 µg/L for ages 50–59, 60–69, and 70–74 y. HT=high threshold

Figure 2

Cost-effectiveness acceptability results for the “contemporary” and “selective” treatment scenarios at willingness to pay levels of $50,000–$150,000 per quality-adjusted life year gained. The strategy numbers relate to the strategies in Table 2. The percentages noted in the figure relate to the proportion of simulation runs in which the cost per quality-adjusted life year was less than or equal to the given willingness to pay. We do not report results for strategies with PSA threshold for biopsy of 10.0 µg/L in the “selective” treatment scenario because cases detected by screening are unlikely candidates for conservative management with delayed curative treatment.