Prostate Screening in the Elderly-High Costs, Few Benefits

Men aged 75 and older generally do not benefit from prostate serum antigen (PSA)-based annual screening. But a new study published in Cancer shows that Medicare spending on PSA screening for men over 75 continues. Xiaomei Ma, PhD, of the department of epidemiology and public health at the Yale University School of Medicine in New Haven, Conn., and colleagues found that Medicare spent approximately $145 million annually on PSA-based screening for men over age 75.

The results also show that while the cost of the PSA screening test did not vary greatly, the main cost driver was follow-up biopsy. The frequency of biopsies varied considerably depending on US geography, contributing to much of the annual cost. Regions with higher screening costs had higher rates of prostate cancer diagnosis.

While PSA screening for older men remains controversial, cost is rarely considered, according to the authors of the study. Ma along with colleagues at the Yale Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center and the New York University Langone Medical Center followed a cohort of 94,652 Medicare beneficiaries between the ages of 66 and 99 who had no prior history of prostate cancer starting in 2006. The men’s PSA screening and associated procedures, including costs, were tracked for 3 years.

About 51% of the men had PSA screening tests in the 3 years of follow-up and 3% had a biopsy. The total annual cost to the Medicare program for the prostate cancer screening was $447 million in 2009 US dollars.

Individual PSA screenings were only a small portion of the overall screening cost, with average yearly costs at the regional hospital level between $17 and $62 for each Medicare beneficiary. Follow-up tests and biopsies accounted for the majority of the spending-72% of the total annual cost in the United States.

Each hospital referral region, made up of over 100 Medicare beneficiaries, was classified into four quartiles based on screening cost and screening intensity.

“Our results suggest that the overall cost of prostate cancer screening may be heavily influenced by how urologists choose to respond to the result of a PSA test, more so than the use of the PSA itself,” said Ma in a statement.

These results suggest that urologists and oncologists in different geographic regions have varying opinions on PSA screening and how to follow through on the test results. “Our results show that the cost of prostate cancer screening is heavily influenced by how health care providers act upon PSA findings, not just whether a PSA test was ordered initially.”

What factors influence these regional trends is not clear, but future studies should aim to understand these factors as well as how PSA screening and follow-up tests are influencing prostate cancer outcomes in the long term.

Currently, the US Preventative Services Task Force does not recommend PSA screening for men of any age based on evidence that most prostate cancers are slow growing and not likely to become symptomatic within a decade of such early-stage diagnosis. Follow-up biopsies after PSA testing are invasive and can do more harm than good, according to experts. But, not promoting screening remains controversial and Medicare still covers PSA screening and the follow-up tests for men.

Medicare beneficiaries undergoing biopsies may also be treated, adding additional Medicare spending. This type of care could be unnecessary and come with the burden of side effects, according to Cary Gross, MD, professor of internal medicine at Yale School of Medicine, and director of the Yale COPPER Center. “In order to truly understand the costs of screening, the next step is to identify how many additional cancers are being diagnosed and treated as a result of screening older men for prostate cancer. We need better tools to target screening efforts toward those who are likely to benefit,” said Gross in a statement.