Pathways to cost-effective prevention, detection and treatment of prostate cancer in Australia: achieving goals for Australia's health to 2000 and beyond

The current review supports the recommendations of the Australian Health Technology Advisory Committee (AHTAC) against the screening of asymptomatic men for prostate cancer. Australian researchers should link in with two large randomised controlled trials of prostate cancer interventions being undertaken in the USA and Europe; and consider more disaggregated and carefully targetted screening and treatment strategies. Treatment staging. The use of pelvic CT and bone scans for clinical staging in patients with Prostate Specific Antigen (PSA) level of less than 20 ng/ml should not be advocated because they have a very low yield and are not cost effective. The use of modified pelvic lymphadenectomy for staging either by open or laparoscopy is also questioned because the yield of positive diagnosis is very low. Open staging pelvic lymph node dissection (PLND) may no longer be justified for patients undergoing radical retropubic prostatectomy.. Androgen blockade combined with flutamide can reduce the relative risk of progressive disease by 25%. For minimal disease the average survival is increased by 5.2 months at an incremental cost of $25,300 per LYG. For severe disease, average survival increased by 4 months at an incremental cost of $20,000 per LYG. Flutamide shows promise with incremental costeffectiveness being more favourable than most therapies. Screening. A recent comprehensive US study found that optimal Prostate Specific Antigen (PSA) for the initial screening decision was 3.0ng/ml, but rose to 5.0ng/ml in combination with Digital Rectal Examination (DRE). Age related PSA performed no better than PSA. Rather than perform systematic biopsy on all patients with PSA levels higher than 4ng/ml, it may be possible to achieve a 16-5 5% reduction in biopsies (with a respective cancer loss of 4-25%) by limiting biopsy to those with an increased PSAD (Prostate Specific Antigen Density) level and/or abnormal results of DRE. The greatest biopsy reduction relative to cancer yield and lowest cost per cancer detected occurred with PSAD-driven biopsy strategics. A Swedish study found that the most cost-effective approach involved Transrectal Ultrasound (TRUS) of males with PSA of 4ng/ml or greater at a cost of $4,590 per cancer treated for cure. It detected 80% of the cancers actually treated for cure. The US Office of Technology Assessment estimated the cost per lifeyears saved at age 65 was $14,200, increasing to $51,290 per life year saved at age 75. However, this analysis used favourable assumptions about disease progression rates and treatment effectiveness and did not incorporate quality of life measures.