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CA: A Cancer Journal for Clinicians, Vol 43, Issue 3 134-149, Copyright © 1993 by American Cancer Society
P. J. Littrup, A. C. Goodman and C. J. Mettlin
Cost-effectiveness calculations of prostate cancer early detection have not
been possible due to the lack of any data demonstrating reduction in
mortality from any test or procedure. Prior analyses focused only on cost
assessments without consideration of any possible benefits. We used current
data from three consecutive years of the American Cancer Society-National
Prostate Cancer Detection Project to assess different economic perspectives
of test performance, marginal costs, and benefit-cost analysis. The
marginal cost, or cost per cancer, of digital rectal examination (DRE)
markedly increased by the third year relative to several proposed
prostate-specific antigen (PSA) scenarios. Sensitivity analysis for average
cost showed that at 4 ng/ml, pricing PSA below $30 would be the most potent
factor in potentially lowering costs. Analysis of receiver operator
characteristic curves suggested that optimal performance for PSA may be at
3 ng/ml when combined with DRE or between 2 to 3 ng/ml when used alone.
Benefit-cost calculations demonstrated that DRE when performed by highly
skilled examiners had the lowest cost. However, DRE became one of the most
costly detection scenarios when a minor decrease in performance was
assumed. Sensitivity analysis demonstrated that the three most determinant
parameters of net benefit, in decreasing order, are: specificity, benefits
from earlier therapy, and prevalence. If a slightly more specific PSA assay
is developed, the higher prevalence of clinically detectable prostate
cancer could also make screening less costly than breast cancer screening.
Under the assumptions of these analyses, the combination of PSA and DRE
appears to represent an ethical and economical detection choice for
individual patients in consultation with their physicians. Additional
research is needed to quantify the significance of differences between
different screening strategies.
ARTICLES
The benefit and cost of prostate cancer early detection. The Investigators of the American Cancer Society-National Prostate Cancer Detection Project
Wayne State University School of Medicine, Detroit, Michigan.
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