Roman Gulati, MS; John L. Gore, MD; Ruth Etzioni, PhD
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute, the National Institutes of Health, or the Centers for Disease Control and Prevention.
Acknowledgment: The authors thank Jeffrey Katcher for developing a flexible interface for specifying candidate PSA screening strategies and Drs. Jeanne Mandelblatt and Andrew Vickers for helpful comments on an earlier draft of the manuscript.
Grant Support: By awards R01 CA131874 and U01 CA88160 (National Cancer Institute) and U01 CA157224 (National Cancer Institute and the Centers for Disease Control and Prevention).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1645.
Reproducible Research Statement: Study protocol, statistical code, and data set: Available from Mr. Gulati (e-mail, email@example.com). A detailed model description is available at http://cisnet.cancer.gov/prostate/profiles.html.
Requests for Single Reprints: Ruth Etzioni, PhD, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, M2-B230, PO Box 19024, Seattle, WA 98109-1024; e-mail, firstname.lastname@example.org.
Current Author Addresses: Mr. Gulati and Dr. Etzioni: Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, M2-B230, PO Box 19024, Seattle, WA 98109-1024.
Dr. Gore: Department of Urology, University of Washington, 1959 Northeast Pacific Street, Box 356510, Seattle, WA 98195-6510.
Author Contributions: Conception and design: R. Gulati, R. Etzioni.
Analysis and interpretation of the data: R. Gulati, J.L. Gore, R. Etzioni.
Drafting of the article: R. Gulati, R. Etzioni.
Critical revision of the article for important intellectual content: R. Gulati, J.L. Gore, R. Etzioni.
Final approval of the article: R. Gulati, J.L. Gore, R. Etzioni.
Statistical expertise: R. Gulati, R. Etzioni.
Obtaining of funding: R. Gulati, R. Etzioni.
Administrative, technical, or logistic support: R. Gulati.
Collection and assembly of data: R. Gulati, R. Etzioni.
Gulati R, Gore JL, Etzioni R. Comparative Effectiveness of Alternative Prostate-Specific Antigen–Based Prostate Cancer Screening Strategies: Model Estimates of Potential Benefits and Harms. Ann Intern Med. 2013;158:145-153. doi: 10.7326/0003-4819-158-3-201302050-00003
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Published: Ann Intern Med. 2013;158(3):145-153.
The U.S. Preventive Services Task Force recently concluded that the harms of existing prostate-specific antigen (PSA) screening strategies outweigh the benefits.
To evaluate comparative effectiveness of alternative PSA screening strategies.
Microsimulation model of prostate cancer incidence and mortality quantifying harms and lives saved for alternative PSA screening strategies.
National and trial data on PSA growth, screening and biopsy patterns, incidence, treatment distributions, treatment efficacy, and mortality.
A contemporary cohort of U.S. men.
35 screening strategies that vary by start and stop ages, screening intervals, and thresholds for biopsy referral.
PSA tests, false-positive test results, cancer detected, overdiagnoses, prostate cancer deaths, lives saved, and months of life saved.
Without screening, the risk for prostate cancer death is 2.86%. A reference strategy that screens men aged 50 to 74 years annually with a PSA threshold for biopsy referral of 4 µg/L reduces the risk for prostate cancer death to 2.15%, with risk for overdiagnosis of 3.3%. A strategy that uses higher PSA thresholds for biopsy referral in older men achieves a similar risk for prostate cancer death (2.23%) but reduces the risk for overdiagnosis to 2.3%. A strategy that screens biennially with longer screening intervals for men with low PSA levels achieves similar risks for prostate cancer death (2.27%) and overdiagnosis (2.4%), but reduces total tests by 59% and false-positive results by 50%.
Varying incidence inputs or reducing the survival improvement due to screening did not change conclusions.
The model is a simplification of the natural history of prostate cancer, and improvement in survival due to screening is uncertain.
Compared with standard screening, PSA screening strategies that use higher thresholds for biopsy referral for older men and that screen men with low PSA levels less frequently can reduce harms while preserving lives.
National Cancer Institute and Centers for Disease Control and Prevention.
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Cancer Screening/Prevention, Hematology/Oncology, High Value Care, Prevention/Screening, Prostate Cancer.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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