Prostate cancer testing in Sweden – a study on cost and effectiveness
Prostate cancer is an important public health issue, as it is a major cause of death in men. Early detection through an organized testing program with prostate-specific antigen (PSA) testing and systematic biopsy is not in place in most countries due to the risk of overdiagnosis and overtreatment of low-risk cancers. Now there are two proposed approaches to address this problem; magnetic resonance imaging (MRI) and the serum-based reflex test Stockholm3.
Shuang Hao at the Department of Medical Epidemiology and Biostatistics has aimed in his thesis to characterize the socio-economic burden due to prostate cancer in Sweden and assess cost effectiveness of prostate cancer testing with MRI with or without reflex Stockholm3 test.
What are the most important results in your thesis?
The cost-of-illness study found a significant economic burden for prostate cancer in Sweden, with the largest costs coming from direct healthcare and the informal care provided to patients. Our results now provide reference values for future cost-effectiveness analyzes of prostate cancer screening and treatment.
The cost-effectiveness assessments showed that the introduction of MRI in the PSA screening every 4 years for men aged 55–69 years with or without the so-called reflex Stockholm3 is associated with reduced mortality in prostate cancer and overdiagnosis of low-risk cancer. higher quality-adjusted life years (QALYs), incremental cost-effectiveness ratios classified as a moderate cost per QALY gained in Sweden, and higher probability of being cost-effective than traditional PSA screening. My thesis highlights that MRI-based screening can be considered the optimal option for early detection of prostate cancer in Sweden.
Why did you choose to study this particular field?
Worldwide, prostate cancer screening is only available in Lithuania and Kazakhstan. The major concern is that the widely used PSA testing is accompanied by a large number of unnecessary biopsies, overdiagnosis of low-risk cancers and overtreatment.
Prostate cancer is the most common form of cancer in men in Sweden and has caused a significant disease burden. With more advanced and more costly diagnostic techniques such as the Stockholm3 test and MRI showing evidence of the improved sensitivity and specificity, there was a great need to assess whether these emerging technologies can be effective and cost-effective for the early detection of prostate cancer in Sweden and can thus be considered as an alternative in the formation of a national screening program. This has driven me with devotion to find the answers.
What do you think should be done moving forward in this area of research?
There is much to do ahead. As the organized prostate cancer testing (OPT) projects have started or are planned in 17 out of 21 regions in Sweden, it is crucial to assess the cost-effectiveness of different regional projects and of OPT at the national level before a future national screening program can be formed.
To realize this, a research project needs to do several things; first, to model for the opportunistic screening that reflects the current testing situation in Stockholm/Sweden; second, to extend our microsimulation model by including the measure of PSA density in the base algorithm of OPT. Third, we must incorporate the evidence regarding the subsequent rescreening results from the STHLM3-MRI Reinvite trial; and finally to recalibrate the model. Once these things are achieved, we hope to provide solid evidence on the cost-effectiveness of OPT to policy makers to make informed decisions.
Other considerations
Furthermore, although MRI has been recommended by the national treatment guidelines and by the OPT protocol, it should be noted that there may still be limited access to MRI in some regions that have fewer health resources. An investigation has been conducted to understand whether using the Stockholm3 test and the systematic biopsy could be an option in these areas to address the access problem with MRI and the combined targeted and systematic biopsy. A cost-effectiveness analysis comparing these two testing strategies would be necessary to support decision-making.
Other new technologies currently under investigation may become important components of future tests or care pathways. The artificial intelligence assisted pathology to help predict the risk levels of prostate cancer patients can reduce resource utilization, time and costs. Assigning related therapies to patients with target signatures from the sequencing is expected to improve survival and quality of life for patients with metastatic prostate cancer. Cost-effectiveness analyzes that investigate health consequences and the costs of these techniques are therefore very important.
Measuring health status values along prostate cancer diagnosis and care pathways using the same health outcome instrument is also of high priority. This could systematically reflect the patient-reported outcomes and provide more valid input to future economic evaluations.
International collaborations
With the increasing awareness of the potential benefits of early detection of prostate cancer, many countries have begun to evaluate or plan to assess the cost-effectiveness of prostate cancer cancer screening with different strategies.
Spring open source, well-calibrated and validated microsimulation model has been recalibrated to the UK setting and we are currently supporting our collaborators from the German Cancer Research Center in recalibrating the model to the local setting. We have also been contacted by partners from Switzerland to support the modelling. We are also happy to provide support to other partners.
Prostate cancer testing in Sweden: the interplay between cost and effectiveness. openarchive.ki.se/xmlui/handle/10616/48198
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Karolinska Institutet
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