Prostate cancer (PCa) stands as the most prevalent cancer and the third leading cause of cancer-related deaths among men in Europe. According to data from the European Commission, in 2020, PCa represented a staggering 23.2% of all new cancer cases and accounted for 9.9% of cancer deaths among men. This significant prevalence places a heavy burden on healthcare systems and resources, translating to substantial economic costs. In fact, in 2017, the healthcare expenses relating to PCa in Europe reached an estimated €5.8 billion. Given this profound health and economic impact, early detection of prostate cancer is paramount. Effective early detection strategies cannot only alleviate healthcare expenses but also reduce morbidity and mortality associated with the disease.
Prostate cancer screening has been available since the early 1990s, largely due to the recognised efficacy of prostate-specific antigen (PSA) blood tests in identifying at-risk men. Despite its utility, PSA screening presents challenges such as false positives and negatives, leading to issues like overdiagnosis and overtreatment. Therefore, relying solely on PSA testing without subsequent screening follow-ups is deemed inadequate, often resulting in unorganised screening practices that exacerbate these issues. The European Randomized Study of Screening for Prostate Cancer (ERSPC) has suggested that integrating PSA testing into systematic screening protocols, followed by tailored repeat screenings, could enhance screening outcomes and help to minimise disease-related morbidity and mortality over time.
The critical necessity for a refined screening strategy is underscored by studies demonstrating a decrease in the number needed to treat (NNT) as the follow-up duration extends. For example, the NNT declines from 43 after nine years to 18 after 12 years. While increasing overall incidences, effective screening substantially reduces the occurrence of advanced cancer cases. However, findings from the CAP trial indicate that a single PSA test could drive significant economic burdens through unnecessary screening and treatments, emphasising the imperative of developing a cost-effective strategy to mitigate prostate cancer deaths while alleviating healthcare costs.
Unfortunately, only a handful of European nations have implemented structured PCa screening programmes. Initiatives such as the Lithuanian Early Prostate Cancer Detection Programme and the Swedish Organised Prostate Testing Program aim to standardise screening protocols. However, confusion persists regarding the optimal screening approach, with multiple countries advising against PSA testing in organised frameworks. In light of these discrepancies, various scientific studies have endeavoured to evaluate the health advantages of screening programmes against their healthcare costs through rigorous cost-effectiveness evaluations.
This systematic review aims to present a contemporary analysis of the cost-effectiveness of different PCa screening programmes and the determinants influencing these evaluations. As part of the ‘PRostate cancer Awareness and Initiative for Screening in the European Union’ (PRAISE-U) project, our research concentrates on enhancing early detection and diagnosis of PCa via customised screening strategies in the European Union (EU) and the UK.
Despite some screening programmes demonstrating cost-effectiveness, the discussion surrounding PCa screening remains contentious. It is apparent that the most beneficial strategy for the general male population is still under debate. Factors like individual risk profiles – including age and familial history – coupled with the chosen screening methodologies, can sway these decisions. Given the inefficiency of PSA testing alone, it is critical to pursue a risk-adapted screening framework.
The review reveals pronounced variability in PCa screening practices across European countries, with divergent recommendations. While some nations actively discourage PSA testing, various large-scale studies advocate for its benefits. The analysis underscores significant differences in cost effectiveness among diverse screening strategies, revealing that risk-based screening combined with PSA testing authorised by MRI significantly reduces costs per quality-adjusted life year (QALY).
A growing acknowledgment of the importance of individualised screening is evident, particularly regarding age and risk-based strategies. To optimise screening pathways and address the potential for overdiagnosis, emerging research should prioritise additional tests and risk stratification. The EU Council has reinforced the need for tailored screening initiatives, pushing for new evidence to foster the implementation of systematic screening programmes focused on a risk-based approach.
Our review identifies the potential long-term benefits associated with risk-based screening for improving QALYs, rendering it both cost effective and potentially saving costs on a national scale. Although the findings suggest that tailored screening strategies utilising PSA tests and MRI in advance of any biopsies are optimal, it is crucial to investigate the cost-effectiveness of these strategies further, particularly for older demographics and clinically significant prostate cancers.
While our systematic review compiles current evidence on various screening methodologies, gaps remain, particularly concerning long-term outcomes and the complexities associated with determining the most effective screening practices. Continued investigation is essential to solidify the case for risk-based prostate cancer screening in Europe, paving the way for enhanced early detection methodologies through the PRAISE-U project and beyond.
