Prostate cancer screening said to be “not cost effective”

A new review article in Future Oncology has suggested that

even when based on favorable randomized controlled trials in younger age groups, prostate cancer screening is still not cost effective.

A clinical research team based on New Zealand (Lao et al.) came to this conclusion after evaluating a wide range of published data on the costs associated with screening for and treating prostate cancer, including the cost per cancer detected, the estimated costs per life-year saved, and cost per quality-adjusted life year (QALY) gained.

The most interesting information in this study actually appears to be the extraordinary range of the estimated economic costs: from $3,000 to $729,000 in the US alone for the estimated cost per life-year saved.

The authors argue that

The most appropriate data for economic evaluation of prostate cancer screening should be the cost per QALY gained.

They then go on to note that

The estimated costs per QALY gained by prostate cancer screening were significantly higher than the cost-effectiveness threshold.

Of course the authors’ conclusion can only be reached — or justified — on a societal level (as opposed to an individual level). The cost-effectiveness of annual screening for prostate cancer risk among known groups of high-risk individuals may be a great deal higher than the cost-effectiveness of annual screening for every man in America aged between 45 and 75.

30 Responses

  1. The PSA test was the only warning I had for a Gleason 9 prostate cancer in 2004. I was treated with radiation plus ADT. I will be 86 years old in September and a recent PSA test came back at 0.2 as it has since 2010. I am in excellent health, enjoying life and family, and my beloved wife and I will be celebrating our 60th anniversary this year! I challenge anyone to put a monetary value on that.

  2. I guess we will just have to take their word for it. No data or methods required as support.of their conclusions.

  3. I haven’t see the full text of their paper. I am sure there are data and methods therein.

  4. I was 47 when diagnosed with Gleason 7 prostate cancer 7 years ago. Recently still undetectable after surgery at that time. I suppose that could change some time in the future but I often wonder where I would be if I hadn’t undergone PSA testing at the time. Almost surely would be dealing with something other than organ-confined disease by now. Most likely would be dying of prostate cancer sometime in my future had I not been tested.

  5. Manny, ditto. The only difference is our age, I am 77 and was diagnosed with a Gleason 9 in 2008 and had a radical surgery. My PSA has been 0.015 for the past year or so. Thank heavens for PSA testing.

  6. I agree with Manny in general and with the final five lines of this post, in particular. But taken together the two suggest a problem, unless I am missing something. How do you find a “known group of high risk individuals,” without first testing a lot of men in risk groups that are unknown at first? Maybe you will need to screen “every man in [insert country of choice] aged between 45 and 75.”

    The moral is, that if you want more older men like Manny, then screen all 45- to 75-year-old men. Is that old saw, over-treatment, a real and lasting problem? No. Improve all diagnostic tools, raise taxes if necessary, boot out private insurers and their rich ideologues. Monetary value? A dangerous concept. I do know of one instance where QALY calculations led to rejection of a cancer medication, based on demonstrably actionable grounds of age discrimination. The rejection document said, roughly, that given available finances, the medicine should not be given to men older than N years. It was contested, I think successfully.

  7. Dear George:

    We already know that there are certain factors that are associated with significantly higher risk for a diagnosis of prostate cancer, most notably the following:

    — Being of Black African ethnic origin (e.g., African Americans and Afro-Caribbeans)
    — Having two close male relatives who have previously been diagnosed with clinically significant prostate cancer
    — Coming from a family which includes carriers of the BRCA1/2 genes.

    These may not be the only factors indicative of high risk, but they are already well understood.

  8. Sitemaster, I do not expect an abstract to be complete, however;

    “cost per quality-adjusted life year (QALY) gained”

    The authors argue that

    “The most appropriate data for economic evaluation of prostate cancer screening should be the cost per QALY gained.”

    To argue that an undefined subjective term is “the most appropriate data” is to ultimately say nothing at all.

  9. If one adds the positive value of adding mpMRI screening to supplement PSA screening, we can reduce the number of men receiving unnecessary benign prostate biopsies, and hence lower costs, and improve the QALY ratio of recommending screening.

    The negative predictive value of mpMRI excluding a significant cancer defined as a volume of 0.5 cc of GS7 is over 95%. We need more rigorous studies and better methods, as the long latency to death in prostate cancer creates statistical problems in costs benefits.

  10. Dear Sitemaster,

    I see. I forgot all that. I don’t know if I have any known high-risk factor. The rest stands though, for the reason I gave. Screen as many men aged 45-75 as possible. I thought about this a week ago, and came to the conclusion I stated. These thoughts were motivated by recalling that 71% of the members of the Order Of Medical Specialists in the Netherlands agreed with their heads and the government, to place “ceilings” on total costs (per patient) of life-extending medications. Also by the sudden decision by UNUM and United Health, err sorry, the NHS, to drop about 25 cancer medications from their list of NHS England’s prescribed drugs. That, shortly after publishing a prioritising document that prioritises nothing, but uses a textual fog to sketch three types of cuts for this year. I showed that this publication is incomprehensible and, some think, intended to divert and mislead. This is dangerous to ordinary folk, but not to the current head of the NHS and his lackeys.

  11. Dear George (and others):

    Whether we like it or not, we have reached the point where our ability to develop new tests and new medications that have some (but not necessarily great) benefit has started to outweigh the resources available to pay for these tests and these medicines.

    While it is understandable that people find this disturbing and upsetting, the fact that we have reached this tipping point remains.

    Dr. Princenthal is almost certainly correct: giving every patient who is at risk for prostate cancer based on PSA data an mpMRI before he got a biopsy would undoubtedly lower the number of unnecessary biopsies. However, that problem would be replaced by the fact that — as a society here in America — it is near to certain that we couldn’t afford to give people all those mpMRIs and interpret them accurately (even if the equipment and staff to do it were available).

    I have no idea what we should do about these problems as a society. However, I am very conscious indeed of the problem. From a medical point of view, we can now (regularly) do things that we can’t afford to do in an unbiased manner for everyone who may need those things. (Compare this to the fact that, as a society, there are very few people for whom we can’t afford to facilitate access to aspirin — even a daily aspirin tablet — and consider the benefits that that type of treatment has offered us for the past 100 years and the very limited costs involved; then think about all the people who need a kidney transplant but can’t get one.)

    In the very, very near future, in my opinion, we are going to need to start to make some very hard choices indeed about what medical capabilities we can reasonably expect “society” to pay for and whether we are willing to be taxed sufficiently to make those medical capabilities available to everyone in a non-discriminatory manner. Those of us who have grown up with highly socialized forms of medicine (including the NHS in England and Medicare here in America and the Dutch and Swedish health systems that George has been depending on for many years now) may be faced with some realities that we had never actually thought about very much. Similarly, the makers of drugs and medical equipment and the providers of medical services may be faced with realities about what they can reasonably charge for their products and services, not because patients wouldn’t like to use them but because we simply don’t have the wherewithal to pay what has been charged in the past.

    The average American can’t even imagine what it would be like to be taxed in a nation like Sweden … but of course the average American doesn’t even appreciate what comes in return for that level of taxation. However, even Sweden is reaching the point at which it is starting to have problems maintaining a healthcare system that can provide a very high quality of services for all of its population. No proton beam radiation therapy center in Sweden that I am aware of!

  12. Sitemaster,

    Avoiding the difficult choices that must be made is not well served by simply avoiding tests. Ignorance is a cheap and convenient cost control? Over-treatment is not best contained by under testing.

  13. Well, I consider it irresponsible of these Dutch specialists. Also of the Queen Wilhelmina Fund (KWF Kankerbestrijding), the official Dutch cancer charity, to have agreed with this. For they did not originate the idea, I believe. The cabal of Health Minister + Insurers probably did. Just as the German occupiers in World War II found a compliant mass of collaborators in the medical establishment, so does the present government. This is rooted in Calvinist theology, which has instilled an absolute respect for authority. Any authority. Less than 1.5 hours ago, 100 NHS doctors sent a letter of protest to the government, stating that the current reforms have long gone too far. I doubt that any group of Dutch civil servants would do this in public. Those types murdered my wife’s family without questioning their acts. The same amorality (but great love of their divinity) gets them to agree to such stuff. But on the positive side, there is, or will soon be, one proton beam system here in Uppsala. Friends were led around the place last month. I think the idea is to centralise PBRT at Uppsala, and to have facilities here to house families and friends. But I know no more.

    PS: The letter from the 100 NHS doctors called for the “reinstatement” of the former NHS. That was fine before the Health and Social Care Act of 2 or 3 years ago set up the conditions for irreversible privatisation. Clearly then, there are some doctors and others who do not accept the neoliberal doctrine that private sector policies can most often outdo public sector ones. They, and the British organisation I belong to, Disabled People Against Cuts, are adament about this. Many members fear for their lives, in part thanks to cuts to medical resources. These have been shown to be counterproductive. A formal NHS Reinstatement Bill has been drawn up. The media are too silent, while pundits proclaim the mantras of “rationing of the scarce resources.” A specious notion to which too many agree reflexively, without considering alternative possibilities. The disabled people I know and like, would be satisfied with respectful treatment, decent lives, and in some cases a decent length of life. Instead, something like 73 deaths per week for some period less than one year has been documented. A UN inquiry is under way. It took these people, in several groups, 3 years to accomplish this.

  14. My only regret as a 71-year-old stage pT3bN0M0 survivor is that my GP didn’t send me for a biopsy a few years earlier, before my Gleason 9 escaped and invaded my seminal vesicles. Apparently he was not aware that finasteride cut PSA in half.

  15. Dear George and Mike H.

    First, let me be very clear, I am by no means an advocate for “ignorance as a cheap and convenient form of cost control”! Just because I put information created by others up on this site doesn’t mean I agree with it!

    However, I can not, in all honesty, see how we go on expanding unrestricted access to not particularly effective tests, procedures, and medications for all in the way that we have over the past 30 years while the benefits offered by many of these new techniques and therapies get smaller and smaller and the prices get higher and higher. It is an economically unsustainable model — particularly here in the USA where we can’t even raise taxes to repair our rapidly collapsing social infrastructure (roads, bridges, railways, sewer and water systems, etc.).

    This has relatively little — in my mind — to do with politics, and a very great deal to do with expectation management. We are living in a (western) society in which nearly everyone seem to think they are entitled to every known form of test, treatment, and care regardless of what it may cost and regardless of whether it actually is likely to provide sound, actionable information or a significant likelihood of real clinical benefit. Where is this going to stop? It will only stop when we the patients get a serious understanding of what it is reasonable to expect.

  16. Dear Sitemaster:

    Two points. The 73 deaths occurred within a time window, for ill people subjected to the harmful health assessments known as the Work Capability Assessment. It is one feature of the Department for Work and Pensions. Also, the article about the 100 NHS doctors is here. More than 100 top doctors attack government record on NHS.

  17. I wonder if the “cost per life year saved” is a reasonable proxy for the value of lives lost to prostate cancer-specific causes.

    We need a comprehensive cost-benefit analysis that compares the economic and medical cost of over-treatment with the economic value of loss of life attributable to men with higher-risk disease that die from prostate cancer-specific causes through late diagnosis.

    I do not believe this analysis has been carried out. Personally I would love to participate in such a project with an academic center.

  18. Serious Flaw Suspected in at Least Cost-Per-Life-Year-Saved Part of Lao study

    As with most similar attempts, this study relies on literature review for much of its key data. I strongly suspect it has used a snapshot from the European Randomized Screening Study for Prostate Cancer (ERSPC) for its lives saved number, and, as we know for certain, that is a target that is moving downward rather swiftly as years of follow-up accumulate. If that figure is botched, such as use of 1,000 screenings to save a life — now clearly outdated and irrelevant due to non-compliance and other flaws except as an upper limit, then much of the rest of the analysis is flawed. I’ve seen this so often that I’m highly suspicious that it has happened again. Hopefully they had the sense to stay away from the PLCO data.

    Sitemaster — perhaps a quibble, but important to this former student of political science: you used the phrase in your comment of April 7, 2015 at 1:28 pm “highly socialized forms of medicine (including the NHS in England and Medicare here in America”. I would accept that the VA system in the US is socialized, though it could be viewed as a form of military medicine; but “socialism” means government ownership of the means of production and distribution, not just regulation, which is what all government’s do. Medicare uses private resources for care, not employees of the government, so it is not socialist. I’m not counting on you as an expert in political theory. Thanks for all you do!

  19. Dear Jim:

    With respect to your “quibble”, I would seriously dispute your interpretation of the term “socialized” in this context. Americans often mistake the term “socialized” to imply “socialism” and “socialist”. “Socialized” in this context has nothing whatsoever to do with politics. It only implies that we are talking about a basically equal access system for a highly defined group of people. Everyone in the USA over 65 years of age has access to Medicare (although you can admittedly pay more to get more, e.g. Medicare part D). To that extent, Medicare is a “socialized” system (which we all pay money each year to support while we are working). How the care is delivered is a whole different matter. We are all still paying for it as a society; and the vast majority of those over 65 in America take advantage of Medicare as they age.

  20. I now see how you are using the word. I tend to move straight to its more political meaning.

  21. Dear Sitemaster and JimWaldenfels:

    Actually, the contemporary term for American and European care structures is “managed [or, regulated] competition.” Jim is almost right. That notion is due to Alain Enthoven, who tested it in the Netherlands and to some extent in the UK. It works as Jim describes. The word “socialism” is simply wrong in this context.

    Even the Swedish system, including health, was never socialist. Rather a regulated subsystem of the Swedish mixed economy, which was never socialist and was designed to avoid being socialist. Too many Americans use the word, but it just does not apply here. They have been indoctrinated with fears of any collectivist systems, and use of that one word makes indoctrination simple and deters many from learning about what has actually happened.

  22. Dear George:

    I am intimately familiar with the work of Dr. Enthoven over the past 30 years. You are correct, the implementation of healthcare in the US and in many of the nations around the world is now based on the principles of managed competition. However, there is one thing that is very different about the nature of managed competition in most European countries as opposed to managed competition in the USA.

    In many European nations there is an underlying philosophical premise that all citizens will have access to at least reasonable, basic healthcare services, regardless of one’s financial ability to pay for such services. There is then “managed competition” for levels of service that go above and beyond the basics.

    By contrast, here in America, there is managed competition for any type of healthcare through commercial insurance; there is Medicaid (which most people would tell you doesn’t even get close to basic healthcare in many states); there is Medicare (primarily for the retired); and there is charity care. The idea that “the state” should ensure that all US citizens will have access to at least reasonable, basic healthcare services, regardless of their financial ability to pay is simply not accepted by nearly 50% of Americans, which is why “Obamacare” has been such a divisive issue.

    In America, much of healthcare is very highly politicized. And many Americans do think that European healthcare systems are “socialist” (as opposed to “socialized”). This distinction isn’t even acknowledged or recognized by many Americans (regardless of the methodology used to deliver differing levels of care — e.g., managed competition). To that extent, Jim’s original misinterpretation of my use of the term “socialized” was actually very normal.

  23. ‘In America, much of healthcare is very highly politicized. And many Americans do think that European healthcare systems are “socialist” (as opposed to “socialized”).’

    Big government, communist, anti-American, the ruination of America; are all labels that would do. Sitemaster has described the general mood of many. Like all labels, more truth is hidden than not in the description.

  24. Dear Sitemaster:

    Several points. First, I thought one aim of the ACA is to provide universal coverage with private insurers, although this has not yet been achieved. Maybe I am wrong. Second, Mike is right. The name “Socialism” as used in America conceals what has happened in Europe. It is, I believe, used by opinion makers, to this end. Some of them know better. Third, I forgot to say that Alain Enthoven had something to do with thinking behind the ACA. I do not know what. He gave the de Vries Lectures in the Hague and lectures at the NHS, well before the current privatisation wave (begun in ’79 by Reagan, Thatcher, and Lubbers). His ideas inspired politicians in the UK and Nederland to set up the basis for future privatisation. In the UK 2010 to today and in Nederland 1 January 2006. I was in Holland then and in the UK before then. All this has been documented. A while ago I read that, whilst he is positive about the Dutch system, he is a bit disappointed by the cabal formed by the insurers, to control prices; he might have changed his mind. Wikipedia has an interesting article about him. Some of his writings about the NHS are online, at an NHS political history site. To close, surely it would be good for thought if Americans dropped the S-word in this context. It is a con.

  25. George:

    Whatever the aims of the ACA may have been in the beginning, they were long ago subverted by “Realpolitik,” and that’s assuming it even survives the current round of Supreme Court shenanigans. At best the ACA was only ever intended to offer universal access to health care through private insurance, not to make it happen.

  26. Dear Sitemaster:

    Thanks for that. It is depressing to me. Keeping fingers crossed for the near future but I have heard a bit about the court and Realpolitik issues. The latter were predicted, as the insurers would most likely not want to head towards required coverage. You are right about that: it is the main difference between US and Dutch Regulated Competition. The Dutch insurers are doing something similar, by other means.

  27. Dear George:

    The problem isn’t the insurance companies. The problem is the politics of America and the supposed “rights” of individuals as opposed to the obligations of a society.

  28. A note of thanks, and an added point about “rights” in the ACA (Patient Protection and Affordable Care Act”

    Thanks to all participants in this long exchange, and particularly to our tireless (seemingly) Sitemaster!

    Regarding the ACA, I just want to point out that it is not only about creating access to affordable care, it also includes a list of legal rights for those who already had insurance. Those rights have had a substantial impact on policies, and I won’t say more or characterize that to avoid a political discussion.

  29. I agree. These are difficult notions. It is best to approach them by describing a particular social system. Today, that is much of the world, not any one nation that a person belongs to by citizenship. I fear that business power has triumphed over national sovereignty. If so, then who is obligated to what, in what respects? I do not know. Two days ago this article was published online. If a national government uses neoliberal policies, does it have any obligations to its citizens? Ones that give citizens rights? And vice versa, what obligations do citizens have to a bunch of corporations? Another good source is “The Precariat,” by the labour economist and sociologist Guy Standing. These writings are Eurocentric but versions of their ideas apply to the United States.

  30. OK folks … I think we’re done here. This is, after all, a prostate cancer forum, not a sociopolitical one.

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