PSA Screening Must Be Used Conservatively To Be Cost-Effective Interview with:
HICOR portraits, Nov. 4, 2014 Joshua A. Roth, PhD, MHA Assistant Member AHRQ Patient-Centered Outcomes Research K12 Scholar Hutchinson Institute for Cancer Outcomes Research
Joshua A. Roth, PhD, MHA
Assistant Member
AHRQ Patient-Centered Outcomes Research K12 Scholar
Hutchinson Institute for Cancer Outcomes Research What is the background for this study? What are the main findings?

Dr. Roth: PSA prostate cancer screening is controversial because of uncertainty about the overall benefit-risk balance of screening and conflicting recommendations from a variety of prominent national panels. For example, there is debate about whether the cancer early-detection benefits of screening outweigh potential harms related to overdiagnosis of prostate cancer and associated overtreatment (for example, surgery and/or radiation therapy). However, this benefit-risk balance largely depends on how screening programs are structured (for example, the age range over which screening occurs, how often screened occurs, and the PSA level that triggers biopsies) and how screening detected prostate cancers are managed.

With these factors in mind, we developed a simulation model to estimate the morbidity, mortality, and cost outcomes of many PSA screening approaches that have been proposed by national panels or discussed in the peer-reviewed literature. The model calculates these outcomes using inputs from national databases and major PSA screening clinical trials. The primary outcome of our model was the cost per quality-adjusted life year gained—a measure that reflects the value of medical interventions through impacts on cost, survival, and health-related quality of life. We don’t have explicit rules for willingness to pay per quality-adjusted life year in the United States, but interventions that cost $100,000 to $150,000 per quality-adjusted life year are generally considered to be of at least low to moderate value (whereas, for example, an intervention that costs $400,000 per quality-adjusted life year would be generally considered to be of very poor value).

Using the model, we found that more conservative PSA screening strategies (that is, those with less frequent screening and higher PSA level thresholds for biopsy referral) tended to be more cost-effective than less conservative strategies. Importantly, we found that no strategy was likely to be of high value under contemporary treatment patterns where many men with low-risk prostate cancer (that is, those with a Gleason score lower than 7 and clinical T2a stage cancer or lower) receive treatment with surgery or radiation therapy, but several strategies were likely to be of at least moderate value (cost per qualityadjusted life-year=$70 831-$136 332) with increased use of conservative management (that is, treating only after clinical progression) for low-risk, screen-detected cancers. What should clinicians and patients take away from your report?

Dr. Roth: PSA prostate cancer screening must be used conservatively in order to be even marginally cost-effective. To maximize the cost-effectiveness of PSA screening, it should ideally be combined with conservative management of low-risk prostate cancers detected by screening. What recommendations do you have for future research as a result of this study?

Dr. Roth: More personalized prostate cancer screening strategies are needed to tailor screening approaches to individual patients and further improve benefit-risk balance. By that, I mean rather than using a ‘one size fits all’ approach to screening, strategies should increasingly determine screening frequency, biopsy characteristics of individual patients. Future studies should evaluate the feasibility and comparative effectiveness of personalized screening strategies, and additional cost-effectiveness analyses should be conducted to evaluate if they offer good value. Thank you for your contribution to the community.


Roth JA, Gulati R, Gore JL, Cooperberg MR, Etzioni R. Economic Analysis of Prostate-Specific Antigen Screening and Selective Treatment Strategies. JAMA Oncol.Published online March 24, 2016. doi:10.1001/jamaoncol.2015.6275.

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Dr. Joshua Roth (2016). PSA Screening Must Be Used Conservatively In Order To Be Cost-Effective