Cost analyses of prostate cancer screening: frameworks for discussion. Investigators of the American Cancer Society-National Prostate Cancer Detection Project.

Our recent cost analysis of prostate cancer early detection evaluated the economic performance of various prostate specific antigen (PSA) screening approaches, detected marginal cost variations with time and used a benefit-cost calculation as a framework for further discussion. Receiver operator characteristic analysis initially suggested an optimal test performance for PSA of 2 to 3 ng./ml. when used alone and at approximately 3 ng./ml. in combination with digital rectal examination. However, lower PSA decision levels require cost justifications. Marginal cost analysis demonstrated markedly decreased use of digital rectal examination by year 3 due to significantly lower sensitivity for incident cancer. The benefit-cost equation acknowledges that many parameters of cost and probability are not definitive to date yet illustrated major points for discussion. The cost parameters most sensitive to incremental change in decreasing order are the specificity of the screening test, benefits obtained from early therapy and prevalence of the disease. Discussions about improving the likelihood of overall benefit for the United States population should focus on these parameters, as well as social and ethical implications. If we assume minimized future expenditures for terminal cancer care via decreases in therapy choices or coverage, no economic benefit for screening exists. If we also assume that potential costs to society are not roughly approximated by any benefits, we may engender inappropriate attempts at cost reduction by effectively discouraging screening in the highest risk groups. Perhaps the greatest immediate cost control issue is the marked increase in prostate cancer detection in the oldest age groups who have the least likelihood of mortality or morbidity benefits. Current cost savings may be possible with improved public health education about the appropriateness of early detection in the oldest age groups or those with significant preexisting medical conditions.