Simulation Study Based on ERSPC Data Shows Greatest Cost-Effectiveness With Two to Three PSA Screenings Between 55 and 59 Years of Age
The European Randomized Study of Screening for Prostate Cancer (ERSPC) trial showed a significant 29% prostate cancer mortality reduction with prostate-specific antigen (PSA) screening but a marked negative impact on quality-adjusted life-years gained due to the effect of overdiagnosis on quality of life. In a simulation study based on ERSPC data reported in the Journal of the National Cancer Institute, Heijnsdijk et al found that cost-effectiveness of screening was optimal when it was limited to two to three screens between the ages of 55 and 59 years.
Study Details
In the study, numbers of prostate cancers diagnosed, prostate cancer deaths averted, life-years and quality-adjusted life-years gained, and cost-effectiveness of 68 screening strategies starting at age 55 years with a PSA threshold of 3 were predicted using microsimulation modeling. The screening strategies included different age ranges and screening intervals (1–14 years and once only). Costs used 2008 U.S. dollars.
More Favorable Cost-Effectiveness With Shorter Intervals at Younger Ages
Screening at intervals of ≤ 3 years was more cost-effective than longer screening intervals and strategies using more frequent screening over a limited age range resulted in increased life-years gained without a substantial increase in overdiagnosis rate. For examples, a strategy of a single screen at age 55 years yielded a 5% mortality reduction, 30% overdiagnosis, 18 life-years and 17 quality-adjusted life-years gained per 1,000 men, and a net cost per quality-adjusted life-year gained (3.5% discounted) of $31,467. Screening every 2 years at age 55 to 69 yielded a 30% reduction in cancer mortality, 43% overdiagnosis, 83 life-years and 61 quality-adjusted life-years gained, and a net cost per quality-adjusted life-year gained of $120,185. Screening every year at ages 55 to 75 years yielded a 40% reduction in cancer mortality, 48% overdiagnosis, 102 life-years and 64 quality-adjusted life-years gained, and a net cost per quality-adjusted life-year gained of $320,042.
The most favorable results were observed with screening cessation before age 60 years, with screening beyond 63 years of age being associated with loss of quality-adjusted life-years due to overdiagnosis. The incremental cost-effectiveness ratios of these strategies ranged from $31 467 to $72, 971 per quality-adjusted life-year gained. The strategy of screening at 2-year intervals between the ages of 55 and 59 years was considered the most optimal strategy, yielding an incremental cost-effectiveness ratio of $73,000 per quality-adjusted life-year gained, with a 13% reduction in prostate cancer mortality and 33% overdiagnosis rate. Sensitivity analysis indicated that when better quality of life in the post-treatment period was assumed, continuing screening until age 65 to 72 years was associated with favorable cost-effectiveness.
The investigators concluded: “Prostate cancer screening can be cost-effective when it is limited to two or three screens between ages 55 to 59 years. Screening above age 63 years is less cost-effective because of loss of [quality-adjusted life-years] because of overdiagnosis.”
Eveline Heijnsdijk, PhD, of Erasmus Medical Center, Rotterdam, is the corresponding author for the Journal of the National Cancer Institute article.
The study was supported by grants from the Netherlands Organisation for Health Research and Development, Dutch Cancer Society, Europe Against Cancer, and the fifth and sixth framework program of the European Union. For full disclosures of the study authors, visit jnci.oxfordjournals.org.
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