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This article was originally published in The Gray Sheet

Executive Summary

DIGITAL RECTAL EXAM COMBINED WITH PSA TESTING AT 4 NG/ML IS "LEAST COSTLY" approach to early detection of prostate cancer, according to a study published in the May/June issue of CA, an American Cancer Society journal. "The combination of DRE and PSA [prostate specific antigen testing] at 4 ng/ml markedly improves sensitivity and currently represents the least costly detection approach to potentially decrease the mortality from prostate cancer," Peter Littrup, MD, Wayne State University, Detroit, et al. state. The study is entitled "The Benefit and Cost of Prostate Cancer Early Detection." Because data from randomized, controlled studies has not yet emerged to demonstrate a reduction in prostate cancer mortality from early detection, the authors note, prior analyses of detection methods have focused on cost assessment alone, "without consideration of any possible benefits." The current study, by comparison, looks at possible benefits besides improved mortality, such as future medical savings from treating earlier cancer and reduced suffering from prevention of advanced disease. The study is based on data from three consecutive years of the American Cancer Society's National Prostate Cancer Detection Project, a multicenter trial initiated in 1987 to assess the feasibility of early prostate cancer detection by DRE, transrectal ultrasound (TRUS) and PSA testing. As of January, ACS-NPCDP had collected three-year data on 1,449 patients. The analysis itself is modeled after an economic framework developed for gonorrhea screening. "The generalized nature of [the gonorrhea project's] aggregate-benefits equation provided an excellent format to use the current ACS-NPCDP data," the authors note. "Benefit-cost calculations demonstrated that DRE when performed by highly skilled examiners had the lowest cost," the study states. "However, DRE became one of the most costly detection scenarios when a minor decrease in performance was assumed." "Detection approaches using PSA alone at either 3 or 4 ng/ml, or their combination with DRE, all suggested a lower cost of early detection than do more generalized DRE detection efforts," the study found. "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." Development of such an assay should be "highly encouraged," the study states. The authors note that PSA pricing is a "crucial" element in cost-benefit decisions. "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." Ultimately, "[t]he cost effectiveness of prostate cancer early detection cannot be directly calculated without evidence to suggest decreased mortality from any screening approach," the authors acknowledge. "Decisions regarding early detection may remain an individual decision between patient and doctor, yet our current data suggest that early detection could become even more economical than other accepted screening programs" such as breast cancer. "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."

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