BERKELEY, CA (UroToday.com) - Our recent analysis sought to examine the drivers of variation in uptake of PSA testing as a screening mechanism for prostate cancer (PCa) across the EU. With over 350 000 new cases diagnosed in the EU-27 in 2008, PCa is the most common cancer affecting men in the developed world.[1, 2, 3] European countries are aging at a faster rate than previously witnessed, and with this comes an increased demand for screening for PCa, given the increased incidence in older men. Therefore, the observed prevalence of PCa is likely to increase, and with it, demands for an appropriate policy response. Despite concerns having been expressed internationally in regard to prostate specific antigen testing (PSA) as a method for the secondary prevention of PCa, it is the most popular PCa-screening technique utilised worldwide.[4, 5, 6] From an economic perspective alone, high levels of PSA testing not only consume resources but can also be said to contribute, inter alia, to a false impression of the magnitude of the problem, of the extent of variations between countries in prevalence, and finally to inappropriate policy responses in terms of the priority accorded consequent diagnostic services. Given current economic conditions that pose fiscal restraints across the EU, rising costs of follow-on procedures resulting from positive PSA tests may represent a sizable burden of unwarranted health care expenditure. While uptake has been examined at the level of individual countries, to the best of our knowledge there has not been a comparative analysis of uptake across the EU-27.[7, 8] This paper examined variations in uptake of PSA testing across Europe. We controlled for individual characteristics to focus attention on the role of the broader policy context within which individual decisions are made, and in particular, the role of the primary-care physician in the health care system.
Eurobarometer 66.2 “Health in the European Union” 2006 data on self-reported uptake of screening was analysed. Data related to 6 986 men aged 40 and over from 29 European countries. With respect to prostate cancer screening, respondents were asked whether they had a prostate specific antigen test (PSA) in the previous 12 months. Answers available were: - “Yes, own initiative;” “Yes, doctor’s initiative;” “Yes, screening programme;” “No” and “Don’t know.” Due to the framing of this question, the authors were permitted to examine not just whether or not the respondent availed of the screen, but also who initiated the offer. A series of logistic-regression analyses examined the role of individual characteristics across and within countries using the three response variables: 1. "Yes, had a screen in the last 12 months;" 2. "Yes, had a screen in the last 12 months at the doctor’s request;" 3. "Yes, had a screen in the last 12 months at my own request." In additional analysis, differences between countries in terms of the gate-keeping role accorded the general practitioner (GP) in the healthcare system and of level of income inequality, as well as income included as GDP per capita, were explored.
A range of individual characteristics were found to be statistically significant predictors of uptake, including education, marital status, and smoking status; this was consistent with a previous analysis carried out in the Republic of Ireland by the authors.[7] Socio-economic status (SES) was also a statistically significant predictor of the likelihood of screening, with higher SES groups being more likely to get screened compared to lower SES groups. Variation across countries in uptake was evident; importantly a significant role was accorded primary care in explaining variation in uptake. Notably, in health care systems where the GP is assigned a gate-keeping role, uptake is significantly lower overall - with respect to respondent-initiated screening, as well as achieving borderline significance with respect to doctor-initiated screens. For example, in the UK, where a GP gate-keeping function is in place, men were 31% less likely to undertake screening initiated by the GP and 87% less likely to initiate the screen themselves compared to that of the base category, Germany (P< 0.01). Conversely, in France where there is no GP gate-keeping function, men are 124% more likely to undertake screening as initiated by the GP and 83% less likely to initiate the screen themselves compared to that of the base category, Germany (P < 0.01).
While a consensus on the effectiveness of PSA screening has yet to emerge, uptake over a 12 month period in several European countries suggests the test is utilised almost on a routine basis among those aged over 40 in some countries. Significant variation exists between individuals in terms of uptake as well as between groups, depending on who initiated the test. While men aged 70 and over are 185% more likely to have a test than those aged 40-54 (base category), they are 326% more likely to have had a test initiated by the doctor compared to the base (P < 0.01 - despite evidence from screening RCT’s across the USA and the EU suggesting screening over the age of 70 is not clinically recommended.[6] Similarly, with respect to marital status, while those who are married are approximately 20% more likely to have a test than those who are not married, they are almost 45% more likely to have initiated the screen. This variation implies that differences may exist between individuals in terms of the doctor-patient encounter from which the decision to test is likely to emerge. Given the trends evidenced in this analysis, the importance of a strong primary care system in which the doctor can not only act as a gatekeeper to other services but also coordinate care, as highlighted by the World Health Organization (2004) and by the European Commission (2010), needs to be the key focus of current health care reforms strategies across the EU.[9, 10] It is evident that the consensus on the merits of PSA testing has yet to emerge; the results here, suggest such consensus and agreement on how to incentivise is desirable.
References:
- Jemal, A. et al. “Global cancer statistics.” CA Cancer J. Clin 2011; 61: 69–90
- Ferlay J, Parkin DM, & Steliarova-Foucher E. “Estimates of cancer incidence and mortality in Europe in 2008.” European Journal of Cancer 2010; 46(4):765–81.
- European Union “The State Of Men’s Health in Europe” 2011 http://ec.europa.eu/health/population_groups/docs/men_health_report_en.pdf ISBN 978-92-79-20167-7 doi:10.2772/60721
- Mackie A. “Screening for Prostate Cancer: review against programme appraisal criteria for the UK National Screening Committee (UK NSC).” 2010 UK National Screening Committee: http://www.screening.nhs.uk/prostatecancer
- Desai M, Rachet B, Coleman MP et al. “Two countries divided by a common language: health systems in the UK and USA.” JR Soc Med 2010; 103:283-287
- Eckersberger, E. et al. “Screening for Prostate Cancer: A review of the ERSPC and PLCO Trials.” Reviews in Urology 2009; 11 (3): 127-133
- Burns R, Walsh B, Sharp L, & O’Neill C “Prostate Cancer Screening practices in the Republic of Ireland- The determinants of uptake.” Journal of Health Services Research and Policy, 2012; Forthcoming
- Walsh B, Silles M, & O’Neill C “The importance of socio-economic variables in cancer screening participation: A comparison between population-based and opportunistic screening in the EU-15” Health Policy 2011; 101:269-276
- WHO/Europe – Health Evidence Network (HEN), "What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services?", Evidence Report, WHO 2004. http://www.euro.who.int/en/what-we-do/data-and-evidence/health-evidence-networkhen/publications/pre2009/what-are-the-advantages-and-disadvantages-of-restructuring-a-healthcare-system-to-be-more-focused-on-primary-care-services
- Joint Report on Health Systems prepared by the European Commission and the Economic Policy Committee (AWG). Occasional Papers 74. December 2010. http://europa.eu/epc/pdf/joint_healthcare_report_en.pdf
Written by:
Richéal Burns,a,* Brendan Walsh,a, b Stephen O’Neill,a and Ciaran O’Neilla as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
a Cairnes School of Business and Economics, NUI Galway, Galway, Ireland
b Department of Health Services, School of Public Health, University of Washington, Seattle
*PhD Candidate/ Health Economist
Department of Economics
Cairnes School of Business and Economics
NUI Galway
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