Comparative effectiveness of prostate cancer screening between the ages of 55 and 69 years followed by active surveillance

BACKGROUND: Because of the recent grade C draft recommendation by the US Preventive Services Task Force (USPSTF) for prostate cancer screening between the ages of 55 and 69 years, there is a need to determine whether this could be cost-effective in a US population setting. METHODS: This study used a microsimulation model of screening and active surveillance (AS), based on data from the European Randomized Study of Screening for Prostate Cancer and the Surveillance, Epidemiology, and End Results Program, for the natural history of prostate cancer and Johns Hopkins AS cohort data to inform the probabilities of referral to treatment during AS. A cohort of 10 million men, based on US life tables, was simulated. The lifetime costs and effects of screening between the ages of 55 and 69 years with different screening frequencies and AS protocols were projected, and their cost-effectiveness was determined. RESULTS: Quadrennial screening between the ages of 55 and 69 years (55, 59, 63, and 67 years) with AS for men with low-risk cancers (ie, those with a Gleason score of 6 or lower) and yearly biopsies or triennial biopsies resulted in an incremental cost per quality-adjusted life-year (QALY) of $51,918 or$69,380, respectively. Most policies in which screening was followed by immediate treatment were dominated. In most sensitivity analyses, this study found a policy with which the cost per QALY remained below $100,000. CONCLUSIONS: Prostate-specific antigen–based prostate cancer screening in the United States between the ages of 55 and 69 years, as recommended by the USPSTF, may be cost-effective at a$100,000 threshold but only with a quadrennial screening frequency and with AS offered to all low-risk men. Cancer 2018;124:507-13

The role of modelling in the policy decision making process for cancer screening: example of prostate specific antigen screening

Although randomised controlled trials are the preferred basis for policy decisions on cancer screening, it remains diffcult to assess all downstream effects of screening, particularly when screening options other than those in the specifc trial design are being considered. Simulation models of the natural history of disease can play a role in quantifying harms and benefts of cancer screening scenarios. Recently, the US Preventive Services Task Force issued a C-recommendation on screening for prostate cancer for men aged 55–69 years, implying at le

The comparative effectiveness of mpMRI and MRI-guided biopsy vs regular biopsy in a population-based PSA testing: a modeling study

The benefit of prostate cancer screening is counterbalanced by the risk of overdiagnosis and overtreatment. The use of a multi-parametric magnetic resonance imaging (mpMRI) test after a positive prostate-specific antigen (PSA) test followed by magnetic resona

To be screened or not to be screened Modeling the consequences of PSA screening for the individual

Background:Screening with prostate-specific antigen (PSA) can reduce prostate cancer mortality, but may advance diagnosis and treatment in time and lead to overdetection and overtreatment. We estimated benefits and adverse effects of PSA screening for individuals who are deciding whether or not to be screened.Methods:Using a microsimulation model, we estimated lifetime probabilities of prostate cancer diagnosis and death, overall life expectancy and expected time to diagnosis, both with and without screening. We calculated anticipated loss in quality of life due to prostate cancer diagnosis and treatment that would be acceptable to decide in favour of screening.Results:Men who were screened had a gain in life expectancy of 0.08 years but their expected time to diagnosis decreased by 1.53 life-years. Of the screened men, 0.99% gained on average 8.08 life-years and for 17.43% expected time to diagnosis decreased by 8.78 life-years. These figures imply that the anticipated loss in quality of life owing to diagnosis and treatment should not exceed 4.8%, for screening to have a positive effect on quality-adjusted life expectancy.Conclusion:The decision to be screened should depend on personal preferences. The negative impact of screening might be reduced by screening men who are more willing to accept the side effects from treatment

Assessment of harms, benefits, and cost-effectiveness of prostate cancer screening: A micro-simulation study of 230 scenarios

Background: Prostate cancer screening incurs a high risk of overdiagnosis and overtreatment. An organized and age-targeted screening strategy may reduce the associated harms while retaining or enhancing the benefits. Methods: Using a micro-simulation analysis (MISCAN) model, we assessed the harms, benefits, and cost-effectiveness of 230 prostate-specific antigen (PSA) screening strategies in a Dutch population. Screening strategies were varied by screening start age (50, 51, 52, 53, 54, and 55), stop age (51-69), and intervals (1, 2, 3, 4, 8, and single test). Costs and effects of each screening strategy were compared with a no-screening scenario. Results: The most optimum strategy would be screening with 3-year intervals at ages 55–64 resulting in an incremental cost-effectiveness ratio (ICER) of €19 733 per QALY. This strategy predicted a 27

Informed decision-making based on a leaflet in the context of prostate cancer screening

Objective: We aimed to assess to what extent men make informed choices in the context of prostate cancer screening and how written material contributes to that process. Methods: We developed a leaflet describing prostate cancer screening, and a questionnaire consisting of knowledge, attitude, and intended screening uptake components to assess informed decision-making. The leaflet and questionnaire were pilot-tested among men of the target population, adapted accordingly, and sent to 761 members of an online research panel. We operationalized whether the leaflet was read as spending one minute on the leaflet page and by a self-reported answer of respondents. Results: The response rate was 66% (501/761). The group who read the leaflet (n = 342) correctly answered a knowledge item significantly more often (10.9 versus 8.8; p < 0.001) than those who did not read the leaflet (n = 159), and made more informed choices (73% versus 56%; p = 0.001). There were no significant differences in attitude and intended screening uptake between both groups. Conclusion: Having read the leaflet could be one of the factors associated with increased levels of knowledge and informed decision-making. Practical implications: The results of this study showed that increasing knowledge and supporting informed decision-making with written material are feasible in prostate cancer screenin

Evidence for reducing cancer-specific mortality due to screening for breast cancer in Europe: A systematic review

Background: The aim of this study was to quantify the impact of organised mammography screening on breast cancer mortality across European regions. Therefore, a systematic review was performed including different types of studies from all European regions and stringently used clearly defined quality appraisal to summarise the best evidence. Methods: Six databases were searched including Embase, Medline and Web of Science from inception to March 2018. To identify all eligible studies which assessed the effect of organised screening on breast cancer mortality, two reviewers independently applied predefined inclusion and exclusion criteria. Original studies in English with a minimum follow-up of five years that were randomised controlled trials (RCTs) or observational studies were included. The Cochrane risk of bias instrument and the Newcastle–Ottawa Scale were used to assess the risk of bias. Results: Of the 5015 references initially retrieved, 60 were included in the final analysis. Those comprised 36 cohort studies, 17 case–control studies and 7 RCTs. None were from Eastern Europe. The quality of the included studies varied: Nineteen of these studies were of very good or good quality. Of those, the reduction in breast cancer mortality in attenders versus non-attenders ranged between 33% and 43% (Northern Europe), 43%–45% (Southern Europe) and 12%–58% (Western Europe). The estimates ranged between 4% and 31% in invited versus non-invited. Conclusion: This systematic review provides evidence that organised screening reduces breast cancer mortality in all European regions wh

Experiences, expectations and preferences regarding MRI and mammography as breast cancer screening tools in women at familial risk

Background: Several studies have investigated MRI breast cancer screening in women at increased risk, but little is known about their preferences. In this study, experiences, expectations and preferences for MRI and mammography were evaluated among women undergoing screening with MRI and/or mammography in the randomized FaMRIsc trial. Methods: A 17-item questionnaire was sent to 412 women in the FaMRIsc trial. Participants were aged 30–55 years, had a ≥20% cumulative lifetime risk, but no BRCA1/2 or TP53 gene variant, and were screened outside the population-based screening program. Women received annual mammography (mammography-group), or annual MRI and biennial mammography (MRI-group). We asked whether women trust the screening outcome, what they consider as (dis)advantages, which screening they prefer and what they expect of the early detection by the screening tools. Results: 255 (62%) women completed our questionnaire. The high chance of early cancer detection was the most important advantage of MRI screening (MRI-group: 95%; mammography-group: 74%), while this was also the main advantage of mammography (MRI-group: 57%; mammography-group: 72%). Most important disadvantages of MRI were the small tunnel and the contrast fluid (for 23–36%), and of mammography were its painfulness and X-radiation (for 48–60%). Almost the whole MRI-group and half the mammography-group preferred screening with MRI (either alone or with mammography). Discussion: Most women would prefer screening with MRI. The way women think of MRI and mammography is influenced by the screening strategy they are undergoing. Our outcomes can be used for creating information brochures when MRI will be implemented for more women

Cost-effectiveness of surveillance schedules in older adults with non-muscle-invasive bladder cancer

Objective: To estimate the cost-effectiveness of surveillance schedules for non-muscle-invasive bladder cancer (NMIBC) amongst older adults. Patients and Methods: We developed a MIcrosimulation SCreening ANalysis (MISCAN) microsimulation model to compare the cost-effectiveness of various surveillance schedules (every 3 months to every 24 months, for 2, 5 or 10 years or lifetime) for older adults (aged 65–85 years) with NMIBC. For each surveillance schedule we calculated total costs per patient and the number of quality adjusted life-years (QALYs) gained. Incremental cost-effectiveness ratios (ICERs), as incremental costs per QALY gained, were calculated using a 3% discount. Results: As age increased, the number of QALYs gained per patient decreased substantially. Surveillance of patients aged 65 years resulted in 2–7 QALYs gained, whereas surveillance at age 85 years led to 75 years, the incremental yield of QALY gains for any increase in surveillance frequency and/or duration was quite modest (<2 QALYs gained). Conclusion: With increasing age, surveillance for recurrences leads to substantially fewer QALYs gained. These data support age-specific surveillance re