OBJECTIVES: Prostate cancer (PCa) caused 12% of Germany's men’s cancer deaths in 2021. Current early detection guidelines involve digital rectal examination (DRE). PCa can also be detected early using prostate-specific antigen (PSA) testing. PSA testing decreases mortality but can lead to overdiagnosis and overtreatment. There is a growing interest in PSA-based risk-adapted screening and Multiparametric Magnetic Resonance Imaging (mpMRI) techniques which can minimize harm by targeting men at higher risk. This study aimed to recalibrate the Swedish Prostata model to the German context and assess the cost-effectiveness of seven PCa screening strategies.

METHODS: The model was recalibrated to age-specific PCa incidence and Gleason score distributions in Germany from 2014-2019. A cost-utility analysis was conducted from the Statutory Health Insurance (SHI) perspective employing a lifetime horizon starting at age 35. We assumed mpMRI post-diagnosis, with variations during pre-biopsy screening and mpMRI-targeted biopsy [TBx]. Primary outcome measures included lifetime costs and quality-adjusted life years (QALYs). Deterministic sensitivity analyses were performed on utility values, discount rates, screening intervals, starting/stopping ages, and cost parameters.

RESULTS: Compared to no screening, the current German guidelines (DRE+PSA+systematic prostate biopsy [SBx] at 45) exhibited the highest number of deaths averted (70) and the fewest metastatic cancers detected (119) per 100,000 men screened. However, that strategy led to considerable overdiagnosis (137 per 100,000 men), escalated healthcare costs, and cannot be considered cost-effective. Strategies with PSA+MRI+ combined SBx/TBx at 50 and PSA+SBx at 50 demonstrated a substantial reduction in overdiagnosis by 86% and 79%, respectively, compared to the current guidelines. The latter two strategies were cost-effective, with incremental cost-effectiveness ratios below €10,000 per QALY gained compared to no screening.

CONCLUSIONS: The current German guidelines lead to non-negligible overdiagnosis, unnecessary biopsies, and increased healthcare costs. A strong case is made for reassessing these guidelines towards PSA-based risk-adapted screening, with or without mpMRI, starting at 50.