Although most major cancer organizations agree on the guidelines for prostate cancer screening, there is still uneven application of the test, such as in the older patient population, resulting in overdiagnosis and waste in an already fiscally challenged health-care system. Researchers from the University of North Carolina Lineberger Comprehensive Cancer Center conducted a study looking at the costs associated with this practice in the Medicare population.
The ASCO Post spoke with one of the study’s authors, Ronald C. Chen, MD, MPH, Associate Professor, Department of Radiation Oncology, University of North Carolina School of Medicine, about the findings of their study as well as the current state of prostate cancer screening, particularly in older patients.
Please tell us about your study design and results.
Our retrospective study was designed to look at the costs to the Medicare program from the diagnosis and treatment of localized prostate cancer in elderly men. We gathered our data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. We looked at about 50,000 men who were 70 years of age or older and had been diagnosed with localized prostate cancer from 2004 to 2007.
We estimated the Medicare costs associated with prostate-specific antigen (PSA) testing, diagnosis and workup, treatment (either surgical or radiation), follow-up, and side effects associated with treatment. The national Medicare cost estimates were made by using per-patient costs and stage-adjusted incidence rates from the SEER data and census population estimates by age. We found the median cost per patient within 3 years after a diagnosis of prostate cancer was approximately $14,500. And the majority of this cost, not surprisingly, was attributed to treatment. The PSA test is inexpensive, but the downstream costs add up.
We estimated that the annual cost to the Medicare program associated with detecting and treating prostate cancer in men 70 years and older was about $1.2 billion. We also determined that utilizing more active surveillance instead of aggressive treatment with men in this population with a Gleason score of 6 or lower could reduce Medicare expenditures by $451 million.
Are the guidelines that shift every so often currently clear about PSA screening in older men?
As of 2012, the U.S. Preventive Services Task Force (USPSTF) recommended against PSA screening in men of all ages. Many clinicians in the field thought that the recommendation was too restrictive, as many younger patients could benefit from PSA screening. To that end, the USPSTF has since revised the 2012 guideline; now it recommends that younger patients engage in a doctor-patient decision-making discussion about the pros and cons of PSA screening. However, for those older than age 70, the USPSTF still recommends against PSA screening, as does the American Urological Association.
In addition, there are multiple guidelines on managing patients diagnosed with prostate cancer. Both the National Comprehensive Cancer Network® and the American Urological Association recommend active surveillance as the best option for prostate cancers with a Gleason 6 score or lower—and that is regardless of the patient’s age.
What is the value of a doctor-patient conversation?
It is an important conversation between patients and their primary care physician prior to ordering the test, which historically has been part of the routine bloodwork of men after a certain age or with a family history of prostate cancer. This is especially crucial in patients who might have other illnesses and a life expectancy that does not warrant PSA testing. Guidelines are consistent in recommending against PSA screening for men with less than a 10- year life expectancy, because screening in this group of men is unlikely to provide benefit in terms of extending survival and is more likely to cause harm from downstream procedures and treatments. Depending on the patient, a discussion about the risk of false-positive results might also be advised.
What kind of discussion should be expected when a patient is referred to a urologist based on the results of PSA testing?
First and foremost, the urologist should discuss whether a biopsy is warranted. Then, the urologist should also explain the potential risks, although few, involved in a needle biopsy. If a patient has a limited life expectancy and would not benefit from a prostate cancer diagnosis, but a PSA had been checked by the primary care provider, the urologist has an important role in helping the patient make an informed decision about whether to pursue the prostate biopsy.
Recently, the International Society of Urological Pathology introduced a new prostate cancer grading system. What are your thoughts on this new system?
The grade group is essentially a reorganization of the Gleason score that gives a bit more clarity in certain areas of risk. Also, classifying the 5 risk groups as 1 to 5 instead of 6 out of 10 is more understandable for patients, so it could facilitate better communication between physicians and patients.
Please share some closing thoughts on the issue that your study highlighted as they relate to the larger issue of the untenable rise in health-care costs.
It is true that the U.S. health-care system’s rising costs are untenable. There are new treatments that are very expensive, but they clearly help patients. And as a society, we have to decide whether we can provide treatments to our patients that have benefit but are costly. These decisions are difficult.
There are other, perhaps easier, opportunities to reduce health-care costs. The reason we did the study was to look at Medicare expenditures related to PSA screening in older men who are not likely to provide benefit to patients. Finding these opportunities—significant health-care spending that does not benefit, or may even harm, patients—is a better way to curb the rise in spending, and we need more research like this study. ■