Artikel
Whom, when and how to screen? – A decision-analytic view on prostate cancer screening considering personalized risks and preferences
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Veröffentlicht: | 6. März 2018 |
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Gliederung
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Background/Objective: The benefit of prostate cancer (PCa) screening is still controversial due to potential harms from overdiagnosis and overtreatment. We applied the ONCOTYROL Prostate Cancer Outcome and Policy (PCOP) model to evaluate the benefit-harm balance of PCa screening, accounting for familial predisposition, age, individual harm weighting, and active surveillance.
Methods/Material: The PCOP state-transition micro-simulation model simulates the onset and progression of PCa and the beneficial and harmful consequences of screening and treatment on duration and quality of life. Benefit-harm analyses were performed separately for men with average and elevated familial PCa risk. Evaluated screening strategies included one-time screening at different ages, and interval screening at different intervals and age ranges followed by immediate treatment. Optimal strategies maximizing quality-adjusted life expectancy (QALE) were assessed depending on age and individual weighting of harms (disutility). Additionally, screening was evaluated in combination with biennial active surveillance biopsies delaying treatment of localized PCa until progression to Gleason score ≥ 7.
Results: Screening followed by immediate treatment reduced QALE in men with average PCa risk, whereas men with elevated familial risk gained or lost QALE depending on age and disutility. Active surveillance reduced overtreatment by 54-64% and 46-56% in men with average and familial PCa risk, respectively. However, gains by averted overtreatment were opposed by losses due to delayed treatment, especially in the high-risk population with assumingly faster disease progression. Compared to screening with immediate treatment, screening with active surveillance resulted in reduced QALE losses in men with average PCa risk, and reduced QALE gains in men with elevated familial PCa risk.
Conclusions: Benefit-harm predictions of PCa screening models strongly depend on assumptions about PCa risk, prevalence and speed of progression. Based on our decision-analysis, PCa screening in men with average PCa risk yields no net QALE benefit. In contrast, men with familial predisposition may benefit from screening depending on their age and harm weights. Active surveillance can worsen the benefit-harm balance of screening, if QALE gains by averted overtreatment are outweighed by QALE losses due to delayed treatment. Criteria other than Gleason score progression to 7 should be considered for treatment initiation.
Acknowledgment: This work was supported by the COMET Center ONCOTYROL, which is funded by the Austrian Federal Ministries BMVIT/BMWFJ (via FFG) and the Tiroler Zukunftsstiftung/Standortagentur Tirol (SAT).