1
|
Farabi H, Moradi N, Ahmadzadeh A, Aghamir SMK, Mohammadi A, Rezapour A. A cost-benefit analysis of mass prostate cancer screening. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:37. [PMID: 38705990 PMCID: PMC11071254 DOI: 10.1186/s12962-024-00553-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/30/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Prostate cancer (PCa) causes a substantial health and financial burden worldwide, underscoring the need for efficient mass screening approaches. This study attempts to evaluate the Net Cost-Benefit Index (NCBI) of PCa screening in Iran to offer insights for informed decision-making and resource allocation. METHOD The Net Cost-Benefit Index (NCBI) was calculated for four age groups (40 years and above) using a decision-analysis model. Two screening strategies, prostate-specific antigen (PSA) solely and PSA with Digital Rectal Examination (DRE), were evaluated from the health system perspective. A retrospective assessment of 1402 prostate cancer (PCa) patients' profiles were conducted, and direct medical and non-medical costs were calculated based on the 2021 official tariff rates, patient records, and interviews. The monetary value of mass screening was determined through Willingness to Pay (WTP) assessments, which served as a measure for the benefit aspect. RESULT The combined PSA and DRE strategy of screening is cost-effective, yields up to $3 saving in costs per case and emerges as the dominant strategy over PSA alone. Screening for men aged 70 and above does not meet economic justification, indicated by a negative Net Cost-Benefit Index (NCBI). The 40-49 age group exhibits the highest net benefit, $13.81 based on basic information and $13.54 based on comprehensive information. Sensitivity analysis strongly supports the cost-effectiveness of the combined screening approach. CONCLUSION This study advocates prostate cancer screening with PSA and DRE, is economically justified for men aged 40-69. The results of the study recommend that policymakers prioritize resource allocation for PCa screening programs based on age and budget constraints. Men's willingness to pay, especially for the 40-49 age group which had the highest net benefit, leverages their financial participation in screening services. Additionally, screening services for other age groups, such as 50-54 or 55-59, can be provided either for free or at a reduced cost.
Collapse
Affiliation(s)
- Hiro Farabi
- Barts and the London Pragmatic Clinical Trials Unit, Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
| | - Najmeh Moradi
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Abdolreza Mohammadi
- Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
2
|
Michael ZD, Kotamarti S, Arcot R, Morris K, Shah A, Anderson J, Armstrong AJ, Gupta RT, Patierno S, Barrett NJ, George DJ, Preminger GM, Moul JW, Oeffinger KC, Shah K, Polascik TJ. Initial Longitudinal Outcomes of Risk-Stratified Men in Their Forties Screened for Prostate Cancer Following Implementation of a Baseline Prostate-Specific Antigen. World J Mens Health 2023; 41:631-639. [PMID: 36047079 PMCID: PMC10307649 DOI: 10.5534/wjmh.220068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/27/2022] [Accepted: 07/21/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Prostate cancer (PCa) screening can lead to potential over-diagnosis/over-treatment of indolent cancers. There is a need to optimize practices to better risk-stratify patients. We examined initial longitudinal outcomes of mid-life men with an elevated baseline prostate-specific antigen (PSA) following initiation of a novel screening program within a system-wide network. MATERIALS AND METHODS We assessed our primary care network patients ages 40 to 49 years with a PSA measured following implementation of an electronic health record screening algorithm from 2/2/2017-2/21/2018. The multidisciplinary algorithm was developed taking factors including age, race, family history, and PSA into consideration to provide a personalized approach to urology referral to be used with shared decision-making. Outcomes of men with PSA ≥1.5 ng/mL were evaluated through 7/2021. Statistical analyses identified factors associated with PCa detection. Clinically significant PCa (csPCa) was defined as Gleason Grade Group (GGG) ≥2 or GGG1 with PSA ≥10 ng/mL. RESULTS The study cohort contained 564 patients, with 330 (58.5%) referred to urology for elevated PSA. Forty-nine (8.7%) underwent biopsy; of these, 20 (40.8%) returned with PCa. Eleven (2.0% of total cohort and 55% of PCa diagnoses) had csPCa. Early referral timing (odds ratio [OR], 4.58) and higher PSA (OR, 1.07) were significantly associated with PCa at biopsy on multivariable analysis (both p<0.05), while other risk factors were not. Referred patients had higher mean PSAs (2.97 vs. 1.98, p=0.001). CONCLUSIONS Preliminary outcomes following implementation of a multidisciplinary screening algorithm identified PCa in a small, important percentage of men in their forties. These results provide insight into baseline PSA measurement to provide early risk stratification and detection of csPCa in patients with otherwise extended life expectancy. Further follow-up is needed to possibly determine the prognostic significance of such mid-life screening and optimize primary care physician-urologist coordination.
Collapse
Affiliation(s)
- Zoe D Michael
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Srinath Kotamarti
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Rohith Arcot
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kostantinos Morris
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Anand Shah
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - John Anderson
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Department of Family Medicine and Community Health, Duke University Medical Center, Durham, NC, USA
| | - Andrew J Armstrong
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Rajan T Gupta
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Steven Patierno
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Family Medicine and Community Health, Duke University Medical Center, Durham, NC, USA
| | - Nadine J Barrett
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Daniel J George
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Glenn M Preminger
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Judd W Moul
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin C Oeffinger
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Kevin Shah
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Thomas J Polascik
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA
- Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
3
|
Frånlund M, Arnsrud Godtman R, Carlsson SV, Lilja H, Månsson M, Stranne J, Hugosson J. Prostate cancer risk assessment in men with an initial P.S.A. below 3 ng/mL: results from the Göteborg randomized population-based prostate cancer screening trial. Scand J Urol 2018; 52:256-262. [PMID: 30241447 DOI: 10.1080/21681805.2018.1508166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate the long-term outcome of men with an initial prostate-specific antigen (PSA) level below 3 ng/mL and whether the free-to-total (F/T PSA) ratio is a useful prognostic marker in this range. MATERIALS AND METHODS This study is based on 5,174 men aged 50-66 years, who in 1995-1996 participated in the first round of the Göteborg randomized screening trial (initial T-PSA level <3 ng/mL). These men were subsequently invited biennially for PSA and F/T PSA screening until they reached the upper age limit (on average 69 years). Biopsy was recommended if PSA ≥ 3 ng/mL. RESULTS After a median follow-up of 18.9 years, 754 men (14.6%) were diagnosed with prostate cancer (PC). The overall cumulative PC incidence was 17.2%. It increased from 7.9% among men with T-PSA of ≤0.99 ng/mL to 26.0% in men with T-PSA levels of 1-1.99 ng/mL and 40.3% in men between 2-2.99 ng/mL (p < 0.001). The initial PSA was also related to the incidence of Gleason ≥7 PC (3.7% vs 9.7% vs 10.9%) and PC death (0.3% vs 1.1% vs 1.5%). Adding F/T PSA did not improve PC prediction in terms of Harrell concordance index (base model 0.76 vs 0.76) nor improvement of the likelihood of the model (p = 0.371). CONCLUSIONS Some men with initial PSA < 3 ng/mL will be diagnosed too late, despite participating in an organized screening program, indicating that prompt diagnosis is justified in these men. PC incidence and risk of PC death was associated with PSA., but F/T PSA had no predictive value.
Collapse
Affiliation(s)
- Maria Frånlund
- a Department of Urology , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Göteborg, Sahlgrenska University Hospital , Göteborg , Sweden
| | - Rebecka Arnsrud Godtman
- a Department of Urology , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Göteborg, Sahlgrenska University Hospital , Göteborg , Sweden
| | - Sigrid V Carlsson
- a Department of Urology , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Göteborg, Sahlgrenska University Hospital , Göteborg , Sweden.,b Department of Surgery (Urology Service) and Department of Epidemiology and Biostatistics , Memorial Sloan-Kettering Cancer Center , New York , NY , U.S.A
| | - Hans Lilja
- c Departments of Laboratory Medicine, Surgery (Urology), and Medicine (GU-Oncology) , Memorial Sloan-Kettering Cancer Center , New York , NY , U.S.A.,d Nuffield Department of Surgical Sciences , University of Oxford , Oxford , U.K.,e Department of Translational Medicine , Lund University, Skåne University Hospital , Malmö , Sweden
| | - Marianne Månsson
- a Department of Urology , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Göteborg, Sahlgrenska University Hospital , Göteborg , Sweden
| | - Johan Stranne
- a Department of Urology , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Göteborg, Sahlgrenska University Hospital , Göteborg , Sweden
| | - Jonas Hugosson
- a Department of Urology , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Göteborg, Sahlgrenska University Hospital , Göteborg , Sweden
| |
Collapse
|
4
|
Aminsharifi A, Schulman A, Anderson J, Fish L, Oeffinger K, Shah K, Sze C, Tay KJ, Tsivian E, Polascik TJ. Primary care perspective and implementation of a multidisciplinary, institutional prostate cancer screening algorithm embedded in the electronic health record. Urol Oncol 2018; 36:502.e1-502.e6. [PMID: 30170982 DOI: 10.1016/j.urolonc.2018.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/03/2018] [Accepted: 07/23/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE In response to controversy regarding prostate cancer (CaP) screening recommendations, a consolidated Duke Cancer Institute (DCI) multidisciplinary algorithm for CaP screening was developed and implemented. We conducted an online survey within the year following its implementation to assess primary care provider (PCP) attitudes and adoption as well as to evaluate how this program affects screening rates. METHODS A web-based 18-item survey was programmed and was electronically mailed to practicing PCPs at clinics affiliated with the Duke Primary Care system. The survey assessed provider practices and attitudes regarding CaP screening, factors that influenced their general screening recommendations and the confidence related to communicating with patients about screening. The rate of PSA screening before and after implementation of the algorithm was reported across age and race categories. RESULTS In sum, 94 of 106 respondents (88.6%) reported discussing the benefits and harms of screening and let their patients decide (52.8%) or recommended for (31.1%) or against (4.7%) screening. Three-fourths of respondents followed a specific panel recommendation such as the United States Preventative Services Task Force (USPSTF) (48.1%), DCI (20%), or the American Urological Association (AUA) (7.4%) guidelines. After integrating this algorithm into the electronic health record, the rate of prostate screening increased between 11% and 20.4% and 15.6% and 16.4% among different age and race categories, respectively. Overall, 79.2% of PCPs felt very confident regarding their ability to communicate the topic of CaP screening with patients. CONCLUSION The DCI multidisciplinary CaP screening algorithm was well adopted among PCPs shortly after its implementation. The rate of screening increased among all age and race categories thereafter. The majority of PCPs involved in this survey felt confident regarding their CaP screening knowledge and most discuss this topic with patients in a shared decision-making model.
Collapse
Affiliation(s)
- Alireza Aminsharifi
- Division of Urological Surgery, Durham, NC; Department of Urology Shiraz University of Medical Sciences Shiraz, Iran; Duke Cancer Institute, Duke University, Durham, NC
| | | | - John Anderson
- Department of Medicine, Duke Primary Care, Durham, NC
| | - Laura Fish
- Duke Cancer Institute, Duke University, Durham, NC
| | - Kevin Oeffinger
- Department of Medicine, Duke Primary Care, Durham, NC; Duke Cancer Institute, Duke University, Durham, NC
| | - Kevin Shah
- Department of Medicine, Duke Primary Care, Durham, NC
| | | | - Kae J Tay
- Division of Urological Surgery, Durham, NC; SingHealth, Singapore General Hospital, Singapore
| | | | - Thomas J Polascik
- Division of Urological Surgery, Durham, NC; Duke Cancer Institute, Duke University, Durham, NC.
| |
Collapse
|
5
|
Weight CJ, Narayan VM, Smith D, Kim SP, Karnes RJ. The Effects of Population-based Prostate-specific Antigen Screening Beginning at Age 40. Urology 2017; 110:127-133. [PMID: 28842211 PMCID: PMC5730083 DOI: 10.1016/j.urology.2017.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/04/2017] [Accepted: 08/07/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate population-based prostate cancer (CaP) testing of men in their 40s, given the paucity of prospective data evaluating the consequences of prostate-specific antigen (PSA) testing in younger men for CaP. MATERIALS AND METHODS A total of 1052 men in their 40s were followed longitudinally for prostate outcomes, from 1990 to 2010. A random subset of 268 men was selected to undergo biennial CaP testing including PSA testing, transrectal ultrasound, and a digital rectal examination. A representative population of 609 men with a subset of 159 men who also began CaP testing in their 50s was also evaluated as a comparison group. Risk of prostate biopsy (PBx), CaP, or death from CaP was compared between CaP-tested and the routine-care population cohort. RESULTS Median follow-up was 17.2 years. Men aged 40-49, who underwent CaP testing were 2.4 times more likely to undergo a PBx (hazard ratio [HR] 2.4 95% confidence interval [CI] 1.8-3.3) and 2.2 times more likely to be diagnosed with low-risk CaP (HR 2.2, 95% CI 1.12-4.0). Those initiating CaP testing a decade earlier were 2.2 times and 1.7 times more likely to be biopsied and be diagnosed with CaP for any given age (HR 2.2 95% CI 1.4-3.5 and 1.7 95% CI 1.1-2.7, respectively). CONCLUSION CaP testing in men beginning at age 40 resulted in a significant increase in the risk of PBx and diagnosis of low-risk CaP, without a measurable reduction in risk of CaP-death in this low-risk population. However, given the natural history of CaP, a longer follow-up is needed to confirm this finding.
Collapse
Affiliation(s)
| | | | - Daniel Smith
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Simon P Kim
- Department of Urology, Case Western Reserve University, Cleveland, OH
| | | |
Collapse
|
6
|
Knowledge, attitudes, and practices towards prostate cancer screening amongst men living in the southern Italian peninsula: the Prevention and Research in Oncology (PRO) non-profit Foundation experience. World J Urol 2017; 35:1857-1862. [PMID: 28780740 DOI: 10.1007/s00345-017-2074-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/21/2017] [Indexed: 10/19/2022] Open
Abstract
PURPOSE We aimed to explore the knowledge, attitudes, and practices towards prostate cancer (PCa) risk factors and prevention amongst men living in the southern Italian peninsula. METHODS We retrospectively reviewed data collected during free preventive visits carried out by the Prevention and Research in Oncology (PRO) non-profit Foundation between July 2013 and July 2016. The following data were collected: demographic and clinical features, knowledge about PCa prevention and sources of knowledge, knowledge about PCa risk factors, previous prostate-specific antigen (PSA) test, previous digital rectal examination (DRE), previous prostate ultrasound, and general attitudes towards DRE. RESULTS The study population consisted of 2144 Caucasian men living in four regions in the south of Italy (Campania, Calabria, Molise, Puglia). Median age was 59 years. One thousand six hundred and ninety-nine (79.2%) subjects reported knowing the existence of PCa prevention programs. Most of them received information from the media while only 17.1% declared that the information on PCa prevention that they received was from their family physicians. One thousand two hundred seventy-five (59.5%) subjects declared knowing of the existence of PCa risk factors and 41.3% was aware of the existence of both genetic and exogenous factors. The percentage of subjects who reported having had at least one PSA test in their life was 77.8 and 55.4% reported having had a DRE. CONCLUSIONS Knowledge about PCa screening amongst male subjects living in southern peninsular Italy is quite high. Knowledge of PCa risk factors is suboptimal and the practice of DRE is underutilized.
Collapse
|
7
|
Abstract
Prostate cancer is the most commonly diagnosed nonskin cancer in men, with 233,000 new cases estimated for 2014. Nearly 30,000 deaths are predicted for 2014, second only to lung and bronchial cancer deaths. Early diagnosis is key to improving patient survival rates. Screening efforts have dramatically increased the detection rate, and now, 90% of new diagnoses are caught at the early stage of disease. However, new data are driving controversial changes to screening and treatment recommendations.
Collapse
|
8
|
Abstract
PURPOSE OF REVIEW Prostate-specific antigen (PSA) testing provides significant benefits by reducing prostate cancer mortality, but also leads to important harms by detecting clinically insignificant cancers. Hence, there are urgent needs for complementary tools for middle-aged men with modest PSA elevations in blood. This review includes research on prostate cancer biomarkers in blood published from March 2013 through August 2014. RECENT FINDINGS Research progress has been made mainly on PSA as a predictive marker and in the field of kallikrein-based tests: [-2] proPSA, the prostate health index, and a panel of four kallikrein markers. As men with PSA levels below age-median are at very low 20-year risk of metastatic prostate cancer, individualized screening intervals, based on PSA levels, may help in reducing screening costs, prostate biopsies, and detection of insignificant cancer. Statistical models based on kallikrein-markers in blood improve the specificity at modestly elevated PSA (2-10 ng/ml), eliminate unnecessary biopsies, and help selecting men at risk of significant prostate cancer for biopsy or imaging. SUMMARY Individualized, risk-adapted PSA testing intervals and reflex-testing of kallikrein-markers for men with modestly increased PSA values may decrease the harms of screening. However, the clinical value of the proposed testing algorithms and additional tests awaits definitive confirmation in prospective trials.
Collapse
Affiliation(s)
- Ola Bratt
- Nuffield Department of Surgical Sciences, University of Oxford, United Kingdom
- Department of Clinical Sciences, Lund University, Sweden
| | - Hans Lilja
- Nuffield Department of Surgical Sciences, University of Oxford, United Kingdom
- Department of Laboratory Medicine in Malmö, Lund University, Sweden
- Departments of Laboratory Medicine, Surgery (Urology), and Medicine (GU-Oncology), Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
9
|
Sasaki M, Ishidoya S, Ito A, Saito H, Yamada S, Mitsuzuka K, Kaiho Y, Shibuya D, Yamaguchi T, Arai Y. Low Percentage of Free Prostate-specific Antigen (PSA) Is a Strong Predictor of Later Detection of Prostate Cancer Among Japanese Men With Serum Levels of Total PSA of 4.0 ng/mL or Less. Urology 2014; 84:1163-7. [DOI: 10.1016/j.urology.2014.04.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 03/18/2014] [Accepted: 04/05/2014] [Indexed: 10/24/2022]
|