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06-10-2022 | Screening | Adis Journal Club | Article

PharmacoEconomics

Cost-Effectiveness Analysis of Prostate Cancer Screening in the UK: A Decision Model Analysis Based on the CAP Trial

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Authors: Edna Keeney, Sabina Sanghera, Richard M. Martin, Roman Gulati, Fredrik Wiklund, Eleanor I. Walsh, Jenny L. Donovan, Freddie Hamdy, David E. Neal, J. Athene Lane, Emma L. Turner, Howard Thom & Mark S. Clements

Abstract

Background and Objective

Most guidelines in the UK, Europe and North America do not recommend organised population-wide screening for prostate cancer. Prostate-specific antigen-based screening can reduce prostate cancer-specific mortality, but there are concerns about overdiagnosis, overtreatment and economic value. The aim was therefore to assess the cost effectiveness of eight potential screening strategies in the UK.

Methods

We used a cost-utility analysis with an individual-based simulation model. The model was calibrated to data from the 10-year follow-up of the Cluster Randomised Trial of PSA Testing for Prostate Cancer (CAP). Treatment effects were modelled using data from the Prostate Testing for Cancer and Treatment (ProtecT) trial. The participants were a hypothetical population of 10 million men in the UK followed from age 30 years to death. The strategies were: no screening; five age-based screening strategies; adaptive screening, where men with an initial prostate-specific antigen level of < 1.5 ng/mL are screened every 6 years and those above this level are screened every 4 years; and two polygenic risk-stratified screening strategies. We assumed the use of pre-biopsy multi-parametric magnetic resonance imaging for men with prostate-specific antigen ≥ 3 ng/mL and combined transrectal ultrasound-guided and targeted biopsies. The main outcome measures were projected lifetime costs and quality-adjusted life-years from a National Health Service perspective.

Results

All screening strategies increased costs compared with no screening, with the majority also increasing quality-adjusted life-years. At willingness-to-pay thresholds of £20,000 or £30,000 per quality-adjusted life-year gained, a once-off screening at age 50 years was optimal, although this was sensitive to the utility estimates used. Although the polygenic risk-stratified screening strategies were not on the cost-effectiveness frontier, there was evidence to suggest that they were less cost ineffective than the alternative age-based strategies.

Conclusions

Of the prostate-specific antigen-based strategies compared, only a once-off screening at age 50 years was potentially cost effective at current UK willingness-to-pay thresholds. An additional follow-up of CAP to 15 years may reduce uncertainty about the cost effectiveness of the screening strategies.

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Key Points for Decision Makers

Prostate cancer screening is associated with a risk of overdiagnosis of indolent disease and adverse effects associated with biopsy and overtreatment, leading to uncertainty around whether it can be cost effective.

Tailored screening according to a man’s predicted risks may improve the cost effectiveness of screening; however, robust evidence on the long-term effectiveness and cost effectiveness of these approaches is lacking.

This analysis has calibrated a natural history model using rich UK data from the Cluster Randomised Trial of PSA Testing for Prostate Cancer (CAP) and the Prostate Testing for Cancer and Treatment (ProtecT) trial to show that a once-off screen at age 50 years has the potential to be clinically effective and cost effective in a UK setting.