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PSA screens could be cost effective if low-risk cases went untreated

Key clinical point: A modeling study found that screening for prostate-specific antigen could be cost effective if low-risk cases are not treated unless they progress.

Major finding: Screening 55- to 69-year-old men every 4 years and using a PSA biopsy threshold of 3.0 ng/mL was potentially cost effective and also increased quality years of life. The same was true for quadrennial screening of men aged 50-74 years with a biopsy threshold of 4.0 ng/mL.

Data source: A microsimulation model of prostate cancer incidence and mortality.

Disclosures: The study was supported by the National Cancer Institute, the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality. The investigators had no disclosures.

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PSA screening is good when done right

This study forces us to change the debate from “Should we screen?” to “How can we get physicians to follow best practice?” I have heard it said that the professional, financial, and malpractice incentives to screen and then treat low-risk cancer are too overwhelming to allow for significant practice change. But this is clearly disconfirmed by the literature. Use of active surveillance for low-risk prostate cancer has increased fourfold in the past few years; PSA testing in older men has also fallen recently. Rates of unnecessary treatment still remain much too high (about 60%) as does screening of older men (about 35% for those aged 75 years and older). More work needs to be done, and much more change needs to happen.

Andrew J. Vickers, Ph.D.

Based on these results, 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. 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.

Andrew J. Vickers, Ph.D., is at Memorial Sloan Kettering Cancer Center, New York. He reported being named on a patent application for a statistical method to detect prostate cancer; receiving royalties from sales of the test; and having stock options in OPKO Health, which commercialized the test. These comments are from his editorial (JAMA Oncol. 2016 Mar 24 doi: 10.1001/jamaoncol.2015.6276).


 

FROM JAMA ONCOLOGY

References

Given current treatment practices, prostate-specific antigen (PSA) screening is not cost effective unless performed every 4 years in men aged 55-69 years, and with a biopsy threshold of 10.0 ng/mL, researchers reported online in JAMA Oncology.

But several less conservative testing strategies could be cost effective if patients with Gleason scores under 7 and clinical T2a stage cancer or lower are not treated unless they clinically progress, said Joshua A. Roth, Ph.D., of Fred Hutchinson Cancer Research Center in Seattle and his associates.

Joshua A. Roth, Ph.D.

Joshua A. Roth, Ph.D.

The study has “clear implications for the future of PSA screening in the United States,” the investigators wrote (JAMA Oncol. Mar 24. doi: 10.1001/jamaoncol.2015.6275). “Rather than stopping PSA screening, as recommended by the U.S. 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 investigators constructed a hypothetical group of men in the United States who underwent 18 different PSA screening strategies starting at age 40. Under the current treatment paradigm, PSA screening increased years of life by 3%-6%, with a cost of $7,335-$21,649 for each extra year of life. Quality years of life rose only if the strategy included a narrower age range for testing or a biopsy threshold of 10.0 ng/mL.

If the more selective treatment model was used, screening 55- to 69-year-old men every 4 years and using a PSA biopsy threshold of 3.0 ng/mL was not only potentially cost effective, but also increased quality years of life. The same was true for quadrennial screening of men aged 50-74 years with a biopsy threshold of 4.0 ng/mL.

“Our work adds to a growing consensus that highly conservative use of the PSA test and biopsy referral is necessary if PSA screening is to be cost effective,” the researchers concluded. Less frequent screening and stricter biopsy criteria for biopsy were most likely to make screening cost effective, especially if physicians do not immediately treat low-risk cases, they added.

The study was supported by the National Cancer Institute, the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality. The investigators had no disclosures.

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