Abstract
Callender et al. recently published a model-based cost-effectiveness analysis of a risk-tailored approach to prostate cancer screening. It considers the costs and effects of prostate cancer screening offered to all men aged 55-69 without any risk selection and, alternatively, over a range of risk-tailored strategies in which screen eligibility is determined by a varying threshold of disease risk. The analysis finds that the strategy of screening men once they reach a 10-year absolute risk of disease of 5% or more is cost-effective in a UK context. I believe there are several problems with the study, mostly stemming from an incorrect interpretation of the cost-effectiveness estimates. I show that one reinterpretation of their results indicates that screening is much less cost-effective than the original analysis suggests, indicating that screening should be restricted to a much smaller group of higher risk men. More broadly, I explain the challenges of attempting to meaningfully reinterpret the originally published results due to the simulation of non-mutually exclusive intervention strategies. Finally, I consider the relevance of considering sufficient alternative screening intensities. This critique highlights the need for appropriate interpretation of cost-effectiveness results for policymakers, especially as risk stratification within screening becomes increasingly feasible.
Highlights
Callender et al recently published a model-based cost-effectiveness analysis of a risk-tailored approach to prostate cancer screening
It is useful to see how my interpretation of the results presented here is supported by the net monetary benefit (NMB) analysis provided by Callender et al.[1] within a supplementary appendix to their study
The above critique shows that the ratios reported as incremental cost-effective ratios (ICERs) by Callender et al.[1] should not be used to inform prostate screening policy
Summary
The non-mutually exclusive strategies within Callender et al.[1] means the incremental CERs reported in Table 1 correspond to a mixture of different policy choices for men of different lifetime risk. They found no strategy with screening beyond age 59 to be cost-effective, indicating the relevance of considering alternative stopping ages in the case of prostate screening This context of previous research and well-established methods guidance tells us that even if Callender et al.’s1 results can be disaggregated into mutually exclusive strategies for separate sub-groups according to lifetime risk, the resulting ratios would still only represent incremental changes to the start age of screening. Further analysis of their model could usefully indicate what strategies would be most useful to compare and which parameters estimates are the priority to refine
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