SCREENING FOR PROSTATE CANCER IS NEITHER APPROPRIATE NOR COST-EFFECTIVE

The controversy surrounding prostate cancer screening stems in part from the different perspectives of health care policy analysts, practicing clinicians, patients, health insurers, and government agencies. Those who advocate screening emphasize the significant morbidity and mortality associated with prostate cancer. They believe that the current level of experimental evidence supports the concept that aggressive intervention dramatically improves survival among men diagnosed with early-stage disease compared with a more conservative approach, which deals with the clinical manifestations of the natural progression of the disease. 5,13,41,53,58 Those who oppose prostate cancer screening emphasize the lack of experimental evidence supporting the theory that early detection and treatment of this disease substantially lowers cause-specific mortality. They point to the significant morbidity associated with current treatment efforts and conclude that screening is unethical because there is a high probability that screening may cause more harm than good. 2,18,21,30,32,36,56 This debate also exists within a larger discussion concerning the appropriate use of resources within our health care system. Western societies face extraordinary pressures to control health care budgets. Within the United States, legislators have proposed dramatic changes in Medicare and Medicaid, and managed care companies are exploring methods to reign in burgeoning health care expenses. Until recently, society has encouraged clinicians and researchers to do all that was possible to fight disease. Medical interventions based on reasonably sound pathophysiologic principles were often championed until clinical trials proved them worthless. This paradigm has begun to shift in favor of one that has clinicians withhold therapy until scientific evidence supports the benefit of intervention. Eddy 24 has suggested that health care costs can be controlled only when health care allocations are based on the following three principles: (1) there should be convincing evidence that, compared with no treatment, the treatment is effective in improving health outcomes; (2) compared with no treatment, its beneficial effects on health outcomes should outweigh any harmful effects on health outcomes; and (3) compared with the next best alternative treatment, the treatment should represent a good use of resources in the sense that it maximizes the health of the population served, subject to the available resources. Furthermore, he emphasizes that the "burden of proof" justifying medical intervention now rests with those who promote treatment. 23 Within this context, I argue that screening for prostate cancer cannot be justified from a health policy standpoint because the resources necessary to implement a screening program are excessive compared with other demands being placed on health care budgets. Anecdotal support for screening based on individual patients who appear to have benefited from early detection and intervention will always exist. The answer to the more difficult health care policy questions surrounding screening, however, rests on randomized clinical trials and careful, systematic analyses of alternative treatment strategies. Without some attempt at measurement, the uncertainty surrounding cost-benefit estimates can be dramatic. Readers need only reflect on an earlier American Cancer Society endorsement of a protocol proposing six sequential stool tests for the detection of colon cancer. This protocol appeared to have reasonable face validity until Neuhauser and Lewicki 45 demonstrated that the cost per case detected would reach $47 million for the sixth test. Recent published estimates concerning prostate cancer screening suggest that one-time prostate cancer screening for the US male population over 50 years old would cost $12 to 28 billion dollars. 22,40,47 Although some lives may be saved, we must reflect carefully whether this enormous expenditure of resources is justified by a commensurate improvement in the health status of individuals. Alternative investments of these resources that may be worth considering include an increase in basic science research funding to identify potential genetic cures for this disease.