SCREENING FOR PROSTATE-CANCER - A DECISION-ANALYTIC VIEW

Objective.-To determine the clinical and economic effects of screening for prostate cancer with prostate-specific antigen (PSA), transrectal ultrasound (TRUS), and digital rectal examination (DRE). Design.-Deci sion analytic cost-utility analysis comparing four screening strategie s with a strategy of not screening. We assumed that the cancer detecti on rate and stage distribution were predicted by each combination of t ests and that localized cancer was treated with radical prostatectomy. For each strategy, we calculated life expectancy, quality-adjusted li fe expectancy (QALE), and cost-utility ratios for unselected and high- prevalence populations. Data.-Probabilities and rates for clinical eve nts were gathered from published data. We assessed utilities by the ti me-trade-off method using urologists, radiation oncologists, and inter nists as subjects. The Clinical Cost Manager at the New England Medica l Center provided cost data. Results.-ln unselected men between the ag es of 50 and 70 years, screening with PSA or TRUS prolonged unadjusted life expectancy but diminished QALE. Screening with DRE alone yielded no reduction in mortality at any age. All programs increased costs. R esults were sensitive only to assumptions about the efficacy of treatm ent. In high-prevalence populations, screening produced a similar patt ern: gains in unadjusted life expectancy, losses in QALE, and increase d costs. Conclusions.-Our analysis does not support using PSA, TRUS, o r DRE to screen asymptomatic men for prostatic cancer. Screening may r esult in poorer health outcomes and will increase costs dramatically. Assessment of comorbidity, risk attitude, and valuation of sexual func tion may identify individuals who will benefit from screening, but sel ecting high-prevalence populations will not improve the benefit of scr eening.