Abstract FO01-02: Finding common ground on the prostate cancer screening controversy
Authors: Crawford E. David 
Published: January 2014

The 2011 US Preventative Services Task Force (USPSTF) draft policy for prostate cancer screening, which became final this May, might result in significant costs related to disease burden and treatment. We presented an analysis of the recommendations in a late-breaking oral session here at the American Urological association 2012 Annual Scientific Meeting. The USPSTF gave prostate cancer screening a grade of D (not recommended; harm outweighs benefits or no net benefit). However, our analysis suggests that avoiding prostate cancer screening might ultimately cost more in terms of treating advanced disease and missing significant numbers of cases.

Participants of the Prostate, Lung, Colorectal, Ovarian (PLCO) Screening Trail without cancer at T0 (n=33,709) in 2011 formed the basis of their conclusions. Subjects were at least 55 years of age with adequate prostate-specific antigen (PSA) levels or a positive digital rectal exam at entry. A Gleason score of at least 7 defined clinically significant cancer.

Expenses related to prostate cancer were based on Medicare costs and estimates published in 2010. The results were projected to a Surveillance, Epidemiology, and End Results (SEER) incident population with localized cancer (n=202,500).

A total of 2580 men from the PLCO Screening Trial were treated for prostate cancer after T0. Total expenditures were $61.5 million ($23,804 per patient). Estimated total expenditures for 377 treated patients with clinically significant prostate cancer after T0 were $8.6 million ($22,742 per patient). After extrapolation at a national level to 96,000 patients with clinically significant prostate cancer (SEER data), annual initial diagnosis/treatment costs were estimated to be $2.4 billion

Savings at First, But Expenses Later

Adopting draft USPSTF recommendations would result in $2.4 billion in initial savings, however, many of these men will subsequently present with clinically significant prostate cancer, with total treatment costs far exceeding $2.4 billion.

A no-screening' policy is a bad investment at the societal level. It would decrease prostate cancer health expenditure and would miss from 0.57% to 1.22% of significant prostate cancer cases, depending on the amount of increase in the screening interval. Many missed prostate cancer cases will subsequently present with significant prostate cancer [often metastatic], incurring significant consequences and risk, a more rational policy might be to screen appropriate men for prostate cancer for identification and early treatment of clinically significant disease.

A Wake-Up Call

The USPSTF recommendations are a ‘wake-up’ call that is not business as usual with screening. There were warning signs this was coming, and these were ignored, but a lot of the comments in [the USPSTF] paper were very accurate.

I recommend that all interested physicians read the report and that they keep an open mind. We should all work together to address and implement some suggestions, such as extending screening intervals, using better markers of progression, and separating diagnosis from treatment. There needs to be a common ground. The greatest impact of the new recommendations will be on family practice physicians, who have not had a clear understanding of screening and have been victims of many lawsuits related to failure to diagnose the disease. Many will discourage screening.

This presentation will review the pros and cons of screening, current clinical trials and suggest a way forward.

Citation Format: E. David Crawford. Finding common ground on the prostate cancer screening controversy. [abstract]. In: Proceedings of the Eleventh Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2012 Oct 16-19; Anaheim, CA. Philadelphia (PA): AACR; Cancer Prev Res 2012;5(11 Suppl):Abstract nr FO01-02.