Reka%Pataky,%Roman%Gula0,%Ruth%Etzioni%% and%Stuart%Peacock% - PowerPoint PPT Presentation

Reka%Pataky,%Roman%Gula0,%Ruth%Etzioni%% and%Stuart%Peacock% 2012%World%Cancer%Congress% August%28,%2012% Advancing)Health)Economics,) Services,)Policy)and)Ethics)

Background%and%Ra0onale% • Prostate%cancer%is%the%most%common%cancer%in%men% – challenge%is%that%it%is%also%highly%prevalent,%and%many% cancers%are%low%risk% • Elevated%serum%PSA%is%associated%with%cancer%risk% – Test%alone%has%poor%predic0ve%value;%high%false%posi0ve% rate% – Lead%0me%of%6M8%yrs;%overdiagnosis%rates%of%25M40%% • BC%Cancer%Agency’s%Genitourinary%Tumour%Group%and%the% Vancouver%Prostate%Centre%(GUTG/VPC)%recommend%regular% PSA%screening%for%men%who%are%informed%of%poten0al%risks% • BC%Medical%Services%Plan%does%not%cover%PSA%tests%for% asymptoma0c%men% 2%

Background%and%Ra0onale% • Prostate,%Lung,%Colorectal%and%Ovarian%Cancer%Screening%Trial% (PLCO)%% – 77,000%men%aged%55M75%yrs%randomized%to%annual%PSA%test%for%6%yrs%or% usual%care% – No%impact%on%prostate%cancer%mortality%a[er%13%years%(Andriole%et%al.% JNCI%2012)% – Cri0cized%for%high%PSA%tes0ng%rates%in%control%arm%(>40%)% • European%Randomized%Study%of%Screening%for%Prostate%Cancer% (ERSPC)% – 162,000%men%aged%55M69%yrs%randomized%to%PSA%test%every%4%yrs%or% usual%care% – 21%%reduc0on%in%prostate%cancer%mortality%a[er%11%years%(RR%0.79,% 95%%CI:%0.68M0.91;%Schröder%et%al.%NEJM%2012)% 3%

Objec0ve% • To%evaluate%the%costMeffec0veness%of%PSA%screening%strategies% for%BC,%with%and%without%adjustment%for%quality%of%life% • Working%group%of%clinicians%from%the%GUTG/VPC% • Used%Fred%Hutchinson%Cancer%Research%Centre%(FHCRC)% prostate%cancer%model% 4%

FHCRC%Prostate%Cancer%Model% • Discrete%event%simula0on%(Gula0%et%al,%Biosta0s0cs%2010)% • Random%draws%assign:%% – birth%and%death%dates,%date%of%disease%onset,%metastasis,%and%clinical%diagnosis,% disease%grade,%PSA%growth%parameters% • PSA%grows%propor0onal%to%age;%cancer%grows%propor0onal%to%PSA% • Screening%and%biopsy%pakerns%applied%to%natural%history%model%to%give% screen%detec0ons% • Calibrated%to%fit%US%prostate%cancer%incidence%by%age,%stage%and%grade% • Effect%of%PSA%screening%on%mortality%incorporated%using%stage%shi[%% – Mortality%reduc0on%from%ERSPC%study%results,%adjusted%for%nonMakendance,% projected%forward,%and%adjusted%to%US%incidence%and%overdiagnosis%rates% 5%

Adjus0ng%for%Quality%of%Life% ShortAterm) LongAterm) treatment) treatment) effects)(0.88)) effects)(0.90)) Untreated) Screening/) symptoma>c) Healthy)(1.0)) disease)(0.90)) EndAofAlife) care)(0.50)) Distant) disease)(0.85)) ShortMterm%treatment%includes%the%first%year%a[er%diagnosis;%endMofMlife%care%includes% the%last%year%of%life;%untreated%symptoma0c%based%on%clinical%diagnosis%date.%%% Standard%gamble%values%used%where%available.%%% Sources:%Krahn%et%al.%2009;%Krahn%et%al.%2003;%Earle%et%al.%2000% 6%

Screening%Strategies% Age)Range) Interval) PSA)Threshold) Short)Name) 50M75%yrs% 2%yrs% 3.0%ng/mL% 50(2)75% 4%yrs% 3.0%ng/mL% 50(4)75% Adap0ve*% 3.0%ng/mL% 50(A)75% 2%yrs% 3.0%ng/ml;%4.0%ng/mL%for%men%≥70%yrs% 50(2)75,4.0% 40M75%yrs% 2%yrs% 3.0%ng/mL% 40(2)75% 55M75%yrs% 2%yrs% 3.0%ng/mL% 55(2)75% 60M75%yrs% 2%yrs% 3.0%ng/mL% 60(2)75% 50M70%yrs% 2%yrs% 3.0%ng/mL% 50(2)70% 55M70%yrs†% 4%yrs% 3.0%ng/mL% 55(4)70% 50%yrs% Single%test% 3.0%ng/mL% 50(1)% 60%yrs% Single%test% 3.0%ng/mL% 60(1)% 70%yrs% Single%test% 3.0%ng/mL% 70(1)% *%Men%with%PSA%above%the%median%(by%age)%are%screened%again%in%2%years,%all%others%screened%again%in% 4%years% †%Represents%core%ERSPC%trial%group% 7%

Analysis% • Projected%results%for%a%cohort%of%40%yearMold%men%in%the%year% 2000,%to%age%90%yrs% • Counted:%% – cancers%detected%(by%stage),%number%of%overdiagnoses,%prostate% cancer%deaths,%deaths%avoided,%PSA%tests,%false%posi0ves,%biopsies,%lifeM years%saved,%0me%in%state% • Costs%and%benefits%discounted%at%3%/yr% • Sensi0vity%analysis:%% – Screening%and%biopsy%costs%by%25%;%treatment%costs%by%25%;%u0lity% values%+/M%0.05% 8%

CostAeffec>veness)of)PSA)screening) $1'200% $528,000/LYG% 50(1)% $1'000% 60(1)% 70(1)% $800% 55(4)70% Incremental)Cost) $63,900/LYG% 50(4)75% 50(2)70% $600% 60(2)75% $58,400/LYG% 55(2)75% $400% 50(2)75,4.0% 50(A)75% $33,700/LYG% 50(2)75% $200% 40(2)75% "current"% $24,900/LYG% $0% CE%fron0er% 0.000% 0.005% 0.010% 0.015% 0.020% 0.025% LifeAyears)gained) 9%

CostAu>lity)of)PSA)screening)(u>lity)values)+/A)0.05)) $1'200% $1'000% 50(1)% 60(1)% 70(1)% $800% Incremental)cost) 55(4)70% $ 130,000/QALY % 50(4)75% 50(2)70% $600% 60(2)75% 55(2)75% $400% 50(2)75,4.0% 50(A)75% $ 105,000/QALY % 50(2)75% $200% 40(2)75% "current"% $ 94,200/QALY % $0% M0.0300% M0.0250% M0.0200% M0.0150% M0.0100% M0.0050% 0.0000% 0.0050% 0.0100% Incremental)qualityAadjusted)lifeAyears)(QALY))) 10%

Conclusions%&%Next%Steps% • PSA%screening%results%in%a%loss%of%QALYs,%regardless%of% intensity% • If%mortality%reduc0on%is%the%only%goal,%then%PSA%screening%may% be%costMeffec0ve% • Ac0ve%surveillance?% – Men%with%lowMrisk%disease%receive%regular%followMup%with%PSA%tes0ng% and%biopsy,%un0l%progression% – Disconnects%overdiagnosis%and%overtreatment% – Being%added%to%FHCRC%model% 11%

Acknowledgements% • Prostate%Cancer%Modeling%Working%Group%members% – Drs.%Peter%Black,%Kim%Chi,%Andy%Coldman,%Larry%Goldenberg,%Mark% Elwood,%Tom%Pickles,%Scok%Tyldesley% • BC%Cancer%Agency’s%Surveillance%and%Outcomes%Unit% • Cancer%Interven0on%and%Surveillance%Modeling%Network% (CISNET)% 12% Advancing)Health)Economics,)Services,)Policy)and)Ethics)

Current%screening%in%BC% 100%% 80%% 60%% 40%% 20%% 0%% 40M49% 50M59% 60M69% 70M79% 80+% Total% Never%screened% 81.9% 55.1% 42.1% 49.5% 48.9% 61.7% Don't%know/not%stated% 0.0% 0.1% 0.2% 0.1% 0.7% 0.1% 5+%years%ago% 0.6% 1.5% 0.8% 2.1% 5.2% 1.2% 2%M%<5%years%ago% 3.6% 7.0% 10.3% 7.5% 6.2% 6.4% 1%M%<2%years%ago% 5.2% 14.6% 13.8% 12.8% 11.4% 10.6% <1%year%ago% 8.7% 21.8% 33.0% 28.0% 27.5% 19.9% Source:)CCHS)2003) 13%

4'000% 30'000% A) B) Men)with)1+)biopsy)) 3'500% 25'000% Overdiagnoses)) 3'000% 20'000% 2'500% 2'000% 15'000% 1'500% 10'000% 1'000% 5'000% 500% 0% 0% 0% 200% 400% 600% 800% 0% 200% 400% 600% 800% Lives)saved) Lives)saved) 2'000% 25'000% C) D) Men)with)1+)false)posi>ve) PSA)tests)(thousands)) 20'000% 1'500% 15'000% 1'000% 10'000% 500% 5'000% 0% 0% 0% 200% 400% 600% 800% 0% 200% 400% 600% 800% Lives)saved) Lives)saved) 50(1)% 60(1)% 70(1)% 50(2)75% 50(A)75% 50(4)75% 50(2)75,4.0% *All$expressed$per$100,000/men$ 40(2)75% 55(2)75% 60(2)75% 50(2)70% 55(4)70% "current"% 14%

Adding%costs% Unit)cost) PSA%test% $30% Biopsy% $880% Mean)cost) LocalMregional%disease% Conserva>ve)management) $1,200% Radical)prostatectomy) $11,600% Radiotherapy) $12,500% Androgen)depriva>on)therapy) $3,600% Distant%disease% $7,400% EndMofMlife%care% $9,600% Sources:%LifeLabs%BC%(PSA%test%cost);%BCCA%treatment% records;%BC%MSP%fees;%local%caseMcost%es0mates% All%values%2010%CDN%$% 15%