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Cost‐effective prostate cancer detection. Reduction of low‐yield biopsies
Author(s) -
Littrup Peter J.,
Kane Robert A.,
Mettlin Curtis J.,
Murphy Gerald P.,
Lee Fred,
Toi Ants,
Badalament Robert,
Babaian Richard
Publication year - 1994
Publication title -
cancer
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 3.052
H-Index - 304
eISSN - 1097-0142
pISSN - 0008-543X
DOI - 10.1002/1097-0142(19941215)74:12<3146::aid-cncr2820741214>3.0.co;2-z
Subject(s) - medicine , prostate cancer , biopsy , rectal examination , prostate specific antigen , urology , prostate , prostate biopsy , cancer , cohort , gynecology , radiology
Background . In hopes of limiting low‐yield prostate biopsies, results of digital rectal examination (DRE), transrectal ultrasound (TRUS), prostate specific antigen (PSA) and age‐related PSA values, gland‐volume‐adjusted PSA levels, and longitudinal PSA changes were analyzed to identify their cost‐effectiveness as prognostic indicators in screening, biopsy, and follow‐up of patients with prostate cancer. Methods . Twenty‐nine hundred men with complete data sets from an initial cohort of 2999 men with an annual follow‐up for up to 5 years were examined. Intrapatient PSA and gland‐volume variability, optimal PSA operating points (o. P.), and test performance scores were determined for each parameter. Decision analysis was then applied retrospectively to each parameter to determine the cancer detection yield, biopsy requirements, and costs for commonly used detection strategies. Results . For the initial screening decision, the optimal PSA o. p. was 3.0 ng/ml but increased to 5.0 ng/ml in combination with DRE, whereas age‐related PSA performed no better than did PSA. The mean intrapatient variability in TRUS gland volume (+5.5 cc) relative to mean volume (34 cc) was 16%, which was less than the 28% (0.64/2.3 ng/mll relative variability for PSA. For biopsy decisions, using PSA density (PSAD) with a level of 0.12 ng/ml/cc there was no significant difference in accuracy compared with the systematic biopsy of all patients with elevated PSA or age‐related PSA levels. Rather than perform systematic biopsy on all patients with PSA levels greater than 4 ng/ml, decision analysis showed that a 16‐55% reduction in biopsies could be achieved with a respective cancer loss of 4–25% by limiting biopsy to patients with an increased PSAD level and/or abnormal results of DRE. Using age‐related PSA criteria in combination with DRE reduced biopsies by 12% but resulted in minimal cost reductions. The greatest biopsy reduction relative to cancer yield and lowest cost per cancer detected occurred with PSAD‐driven biopsy strategies. During follow‐up, longitudinal changes in absolute PSA and PSAD levels were significantly better ( P < 0.05) than the percentage change in PSA levels per year. Conclusions . Cost‐effective prostate cancer detection with PSA as a parameter is better achieved if screening and biopsy decisions are not linked intimately. A tailored‐biopsy approach for patients with disproportionately elevated PSA levels of suspicious DRE results in the greatest biopsy reduction by selecting lower risk groups for more conservative follow‐up.