Department of Population Health Sciences, Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK.
NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK.
Pharmacoeconomics. 2022 Dec;40(12):1207-1220. doi: 10.1007/s40273-022-01191-1. Epub 2022 Oct 6.
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.
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.
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.
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.
英国、欧洲和北美的大多数指南不建议对前列腺癌进行广泛的人群筛查。基于前列腺特异性抗原的筛查可以降低前列腺癌特异性死亡率，但存在过度诊断、过度治疗和经济价值的担忧。因此，目的是评估英国八种潜在筛查策略的成本效益。
我们使用基于个体的模拟模型进行成本效益分析。该模型根据 PSA 检测前列腺癌（CAP）10 年随访的集群随机试验数据进行校准。使用来自前列腺癌检测和治疗（ProtecT）试验的数据对治疗效果进行建模。参与者是英国 1000 万男性的假设人群，从 30 岁开始随访至死亡。策略如下：不筛查；五种基于年龄的筛查策略；适应性筛查，即初始前列腺特异性抗原水平<1.5ng/mL 的男性每 6 年筛查一次，水平高于此水平的男性每 4 年筛查一次；以及两种基于多基因风险分层的筛查策略。我们假设在前列腺特异性抗原≥3ng/mL 的男性中使用活检前多参数磁共振成像，并结合经直肠超声引导和靶向活检。主要结果指标是从国家卫生服务角度评估预期寿命成本和质量调整生命年。
与不筛查相比，所有筛查策略均增加了成本，而大多数策略也增加了质量调整生命年。在愿意支付 20,000 英镑或 30,000 英镑/质量调整生命年的阈值下，一次性 50 岁筛查是最佳选择，尽管这对使用的效用估计值敏感。尽管多基因风险分层筛查策略不在成本效益前沿，但有证据表明它们比替代基于年龄的策略成本效益更低。
在所比较的前列腺特异性抗原筛查策略中，只有一次性 50 岁筛查在当前英国愿意支付的阈值下具有潜在的成本效益。对 CAP 的额外 15 年随访可能会降低对筛查策略成本效益的不确定性。
