Fig 1.
Prostate cancer screening interventions using PSA test and the S3M reflex test.
Fig 2.
Schematic of the prostate cancer natural history model.
Individuals are assumed to be disease-free at age 35 years. They may progress to preclinical cancer states with a fixed Gleason score, with progression by T-stage and to metastatic cancer. Preclinical cancers may be diagnosed from nine different states, with survival from prostate cancer death evaluated from the possibly counterfactual time of clinical diagnosis. Death due to other causes is represented as a competing event.
Table 1.
Input parameters.
Table 2.
Predicted effects for no screening, PSA screening and S3M screening at 4-year intervals for the ages 55 to 69 years.
The effects are presented as clinical events per 10,000 men, cost as Euros per man and cost-effectiveness as €/QALY. The four right most columns contrasts the clinical and costs as differences and cost-effectiveness as incremental cost-effectiveness ratios.
Fig 3.
Panel (A) shows the cost-effectiveness plane comparing no screening, PSA screening and S3M screening with reflex thresholds at 1 ng/mL, 1.5 ng/mL and 2 ng/mL. The effectiveness and costs are incremental relative to PSA screening and discounted at 3% per annum. Panel (B) shows the ICER (€/QALY) for S3M as a reflex for PSA above 1, 1.5 and 2 ng/mL as functions of the unit cost of S3M. The cost-effectiveness ratios are incremental to PSA screening alone and are discounted at 3% per annum. The current S3M unit cost, of €196, is shown as the grey line. Finally, Panel (C) shows the probability that an intervention is more cost-effective than PSA screening under parameter uncertainty for a specific willingness to pay threshold.
Fig 4.
One-way sensitivity analysis showing the effect of no and high discounting rates, the S3M test performance, high and low biopsy costs, 20% variation in all costs and health state value decrements on the cost-effectiveness.
From the left, the dashed lines show the limits for low (less than €8,300), moderate (€8,300–41,600), high (€41,600–83,300), and very high costs (over €83,300) for Sweden. The bounds for the biopsy costs, together with the urology assessment, varied between €330 and €880.