Economic considerations of prostate cancer. The role of detection specificity and biopsy reduction

Abstract

Background. Prostate specific antigen (PSA) is the most accurate and objective test for of detecting early prostate cancer, yet false-positive elevations have resulted in costly biopsies of many patients at relatively low risk for prostate cancer. A biopsy approach tailored to positive predictive values above 10% is described and the cost implications of improved specificity are addressed by benefit-cost analysis. Methods. Data from recent biopsy decision analyses allowed calculations of overall sensitivity, specificity, and prevalence for various proposed screening options. These were incorporated into the benefit-cost equation, including updates in minor cost changes. Projected 1-year results of systematic biopsy of all patients with suspicious PSA and/or digital rectal examination (DRE) versus the tailored biopsy approach (i.e., biopsy of all patients with PSA density >0.12 ng/ml/cc or concurrently suspicious DRE and transrectal ultrasound) were compared for each screening option. Results. The tailored biopsy approach produced consistent increases in specificity for all screening options, with comparable mild losses in cancer sensitivity. The benefit-cost equation is most sensitive to fluctuations in screening test specificity such that only mild increases in specificity (i.e., 5%) produced marked reductions (50%) in net cost per individual screened. These reductions are greatest for screening approaches using lower PSA values or those including DRE. Conclusions. The most cost-effective approach for any PSA-based, prostate cancer early detection appears to require the use of biopsy protocols tailored to patients at higher risk for prostate cancer. Cancer 1995 ;75 : 1987-93.