title: A Cost-Utility Analysis of Prostate Cancer Screening in Australia.
abstract: OBJECTIVE
  The Göteborg randomised population-based prostate cancer screening trial demonstrated that prostate-specific antigen (PSA)-based screening reduces prostate cancer deaths compared with an age-matched control group. Utilising the prostate cancer detection rates from this study, we investigated the clinical and cost effectiveness of a similar PSA-based screening strategy for an Australian population of men aged 50-69 years.
  
  
  METHODS
  A decision model that incorporated Markov processes was developed from a health system perspective. The base-case scenario compared a population-based screening programme with current opportunistic screening practices. Costs, utility values, treatment patterns and background mortality rates were derived from Australian data. All costs were adjusted to reflect July 2015 Australian dollars (A$). An alternative scenario compared systematic with opportunistic screening but with optimisation of active surveillance (AS) uptake in both groups. A discount rate of 5 % for costs and benefits was utilised. Univariate and probabilistic sensitivity analyses were performed to assess the effect of variable uncertainty on model outcomes.
  
  
  RESULTS
  Our model very closely replicated the number of deaths from both prostate cancer and background mortality in the Göteborg study. The incremental cost per quality-adjusted life-year (QALY) for PSA screening was A$147,528. However, for years of life gained (LYGs), PSA-based screening (A$45,890/LYG) appeared more favourable. Our alternative scenario with optimised AS improved cost utility to A$45,881/QALY, with screening becoming cost effective at a 92 % AS uptake rate. Both modelled scenarios were most sensitive to the utility of patients before and after intervention, and the discount rate used.
  
  
  CONCLUSIONS
  PSA-based screening is not cost effective compared with Australia's assumed willingness-to-pay threshold of A$50,000/QALY. It appears more cost effective if LYGs are used as the relevant outcome, and is more cost effective than the established Australian breast cancer screening programme on this basis. Optimised utilisation of AS increases the cost effectiveness of prostate cancer screening dramatically.
authors.affiliation: University of Queensland, Brisbane, QLD, Australia. Andrewthomaskeller@gmail.com.|Wesley Research Institute, The Wesley Private Hospital, Brisbane, QLD, Australia. Andrewthomaskeller@gmail.com.
authors.forename: Andrew
authors.initials: A
authors.lastname: Keller
authors.affiliation: University of Queensland, Brisbane, QLD, Australia.|Wesley Research Institute, The Wesley Private Hospital, Brisbane, QLD, Australia.
authors.forename: Christian
authors.initials: C
authors.lastname: Gericke
authors.affiliation: University of Queensland, Brisbane, QLD, Australia.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Whitty
authors.affiliation: The Wesley Private Hospital, Brisbane, QLD, Australia.
authors.forename: John
authors.initials: J
authors.lastname: Yaxley
authors.affiliation: The Wesley Private Hospital, Brisbane, QLD, Australia.
authors.forename: Boon
authors.initials: B
authors.lastname: Kua
authors.affiliation: The Wesley Private Hospital, Brisbane, QLD, Australia.
authors.forename: Geoff
authors.initials: G
authors.lastname: Coughlin
authors.affiliation: University of Queensland, Brisbane, QLD, Australia.|The Wesley Private Hospital, Brisbane, QLD, Australia.
authors.forename: Troy
authors.initials: T
authors.lastname: Gianduzzo
mesh_terms: D000368:Aged; D001315:Australia; D003362:Cost-Benefit Analysis; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D017430:Prostate-Specific Antigen / Q000097:blood*; D011471:Prostatic Neoplasms / Q000175:diagnosis* / Q000191:economics; D019057:Quality-Adjusted Life Years
chemical_list: D017430:Prostate-Specific Antigen