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Running head: HOW CAN THE COST/BENEFIT OF PSA TESTING FOR MEN BETWEEN 1
THE AGES OF 40 AND 50 BE MEASURED?
Barbara White
Missouri State University
Running head: HOW CAN THE COST/BENEFIT OF PSA TESTING FOR MEN BETWEEN 2
THE AGES OF 40 AND 50 BE MEASURED?
How Can the Cost/Benefit of PSA Testing for Men Between the Ages of 40 and 50 be
Measured?
Prostate cancer is the second leading cause of cancer death in men in the United States
(Harris et al., 2002; Ferrini & Woolf, nd). The benefit versus the cost of routine screening tests
has been a controversial topic for several years. Prostate cancer is asymptomatic in the early
stages, often leaving it undetected until the disease is advanced. Detecting the cancer in the early
stages improves five year survival due to detection while the cancer is localized (Harris et al.).
However, there is a lack of evidence indicating that earlier treatment improves health outcomes.
The treatment for prostate cancer also has a risk for harm including reduced sexual function,
urinary problems, and bowel problems (Harris et al.). Ferrini & Woolf said that “many men die
with prostate cancer not because of it” (para. 2). The two main screening tests available for
asymptomatic prostate cancer are digital rectal examination (DRE) and prostate specific antigen
(PSA) which is a blood test.
Definitions
The prostate gland is part of the male reproductive system and surrounds the urethra. It
produces a fluid that carries semen (National Cancer Institute [NCI], nd). Prostate cancer
changes the size and shape of the prostate. It is a common occurrence in older men; some
estimates are that 9 of 10 men have prostate cancer at age 80, most without any symptoms
(American Cancer Society [ACS], 2010)
Screening is looking for a disease when there are no symptoms. The purpose is to find
disease in the early stages when there may be a better chance of curing the disease (ACS). The
prostate-specific antigen (PSA) blood test measure the glycoprotein produced by the prostate.
Running head: HOW CAN THE COST/BENEFIT OF PSA TESTING FOR MEN BETWEEN 3
THE AGES OF 40 AND 50 BE MEASURED?
Although blood levels increase with prostate cancer, they also increase with other prostate
conditions (Harris et al.).
Morbitiy is the number of people who have a disease in a population (ACS). Mortality is
the death rate from a specific disease.
Measurement
The most obvious ways to measure the benefits of PSA testing is to examine the
reduction of morbidity and mortality when PSA testing is used. Mortality calculates the number
of deaths caused by prostate cancer. However, the cause of death is not always clear. While
prostate cancer may be present at the time of death, it may not be the cause of death. Alternative
explanations may account for the cause of death (Harris et al.). Morbidity is ineffective in
measuring the effectiveness of PSA testing because the goal of screening is to diagnose more
cancers, at an earlier stage, which would increase the morbidly rate. If screening does not occur,
fewer cancers will be diagnosed. In particular, the cancers that do not become symptomatic will
not be diagnosed.
A third measurement of benefit is survival. Survival is the years of life saved by treating
the disease. To calculate survival rate, the researcher needs to estimate the expected life
expectancy and compare it to the survival rate of all men with who had prostate cancer (Benoit,
Gronberg, & Naslund, 2001). What it cannot account for is quality of life. Do the years at the
end of life expectancy have as much value as those 10 years previous (Benoit et al.)? Are years
spent without the complications of prostate surgery, such as impotence and incontinence, worth
more than years spent with those complications?
Running head: HOW CAN THE COST/BENEFIT OF PSA TESTING FOR MEN BETWEEN 4
THE AGES OF 40 AND 50 BE MEASURED?
Cost is even more difficult to measure. Marginal cost is the cost per cancer per year and
includes diagnostic costs. It is also referred to as cost per cancer over time. Average cost is the
sum of 3 year detection costs divided by the total 3 year detection costs divided by the total 3
year cancer yield. A study in 1993 using these measurements found the benefit-cost calculations
did not justify routine PSA testing (Littrup, Goodman, & Mettlin, 1993).
Cost can also be measured as the fee assessed for the PSA test. It needs to be calculated
for all the years of screening up to the time of diagnosis. Cost also includes a diagnostic biopsy,
bone scan, and treatment of complications (Benoit et al).
Discussion
There are several problems with the measurement information available about PSA
testing. One is that the test cannot differentiate between fast growing and slow growing tumors
so all tumors get biopsied which adds to the cost of screening both in terms of money and
personal anguish over a cancer diagnosis that one should just live with (Harris et al.). Those who
are found to have a fast growing tumor that is prevented from advancing to metastasis certainly
benefit from PSA testing. But a recent European trial found that 48 men would need to be
treated to prevent one death from prostate cancer (ACS).
The average time to death following the diagnosis of prostate cancer is 10 years.
Therefore, the benefit of PSA testing in older men is minimal and the cost is not minimal.
However, younger men between the ages of 50 and 59 are exactly the population who benefit
most from early detection since they have a longer life expectancy and are at greater risk for
faster growing tumors which can spread to other tissues.
Running head: HOW CAN THE COST/BENEFIT OF PSA TESTING FOR MEN BETWEEN 5
THE AGES OF 40 AND 50 BE MEASURED?
Current guidelines reflect these measurement issues. The ACS now recommends that
Primary Care Providers discuss prostate cancer risk with patients and involve the patient in
deciding to screen or not screen based on life expectancy. For those who are at least 50 years old
and expected to live at least another 10 years, PSA testing should be offered. Those men who
have a life expectancy less than 10 years should not be offered PSA testing (ACS).
Prostate cancer has several high risk groups. Men with an immediate family member
who developed prostate cancer before the age of 65 years are at higher risk for aggressive
cancers that shorten life expectancy and should be tested beginning at age 45. Also African
American men are at higher risk and should be tested beginning at age 45. Interestingly, though
a high risk group, little prostate screening research has been done with the African American
population (Harris et al.). While not a measurement problem per se, using measurement for the
most appropriate population is a responsibility of healthcare researchers.
Class Discussion
At the writing of this paper (3 days before the due date) the class discussion reflects many
of the pros and cons to routine PSA testing in men 50-59 that are previously outlined in this
paper. Some classmates feel stronger about the necessity of testing this age group who are most
vulnerable to years lost from even slow growing tumors. Others have found that there is little
conclusive evidence that says routine PSA testing is a strong benefit to men 50-59. This
inconclusiveness of the measurements available to us may be why the American Cancer Society
has directed physicians to decide on a case by case basis after discussion with individual patients.
In this way those who fear having an undiagnosed cancer can receive testing while those who are
Running head: HOW CAN THE COST/BENEFIT OF PSA TESTING FOR MEN BETWEEN 6
THE AGES OF 40 AND 50 BE MEASURED?
not concerned and without risk factors, do not need to be subjected to the cost (time, money,
worry, etc.).
The following is the comment I made on the discussion board to begin our discussion of
PSA testing. After further review of the literature, I still agree with the comments I made, as
have several of my classmates.
I have begun looking at some of the literature about prostate cancer and PSA testing. It
appears that if there is a cost benefit to testing it is this age group, 50-59 year olds,
because they have enough life expectancy remaining to benefit from early detection.
The measurements I have found are of course morbidity and mortality. Morbidity is
complicated by the burdens of the cancer versus the burdens of the treatment, hard to
separate. Mortality is complicated by not knowing individual patients' life expectancies
versus when they actually died. Prostate cancer may not always shorten life.
Cost is apparently a challenge to measure because is measured as cost per cancer over
time. If we test annually over 30 years, the cost is rather high. It is hard to predict which
of those cancers detected would have shortened life expectancy. Prostate cancer is a slow
growing tumor (White, posted on Blackboard, 9/4/10)
Running head: HOW CAN THE COST/BENEFIT OF PSA TESTING FOR MEN BETWEEN 7
THE AGES OF 40 AND 50 BE MEASURED?
References
American Cancer Society (2010). Prostate Cancer Overview. Retrieved September 10, 2010
from http://www.cancer.org/Cancer/ProstateCancer/OverviewGuide/index.
Benoit, R., Gronberg, H., & Naslund, M. (2001). A quantitative analysis of the costs and
benefits of prostate cancer screening. Prostate Cancer and Prostatic Diseases, 4, 138154.
Ferrini, R. & Woolf, S. (nd). Screening for Prostate Cancer in American Men: American
College of Preventive Medicine Practice Policy Statement. Retrieved August 26, 2010
from www.acpm.org/prostate.htm.
Harris, R., Lohr, K., Beck, R., Fink, K., Gosley, P., & Bunton, A. (2002). Screening for prostate
cancer. Agency for Healthcare Research and Quality (US), October.
National Cancer Institute (2010). Fact Sheet: Early Prostate Cancer. Retrieved September 10,
2010 from http://www.cancer.gov/cancertopics/factsheet/Detection/PSA