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Prostate cancer remains a major public health challenge worldwide and has defied efforts to develop effective and acceptable therapy for its control. This reality provides a strong rationale for focusing on prevention. In the Prostate Cancer Prevention Trial (PCPT), the 5α-reductase inhibitor finasteride reduced the prevalence of prostate cancer by 24.8% (versus placebo) in 18,882 men randomized to treatment with that agent (1). Despite this definitive evidence of risk reduction, finasteride has generally not been accepted clinically. The reports by Lucia and colleagues (2) and Redman and colleagues (3) in this issue of the journal do much to address the paradox that one of the most successful findings of prevention trials has not resulted in widespread acceptance. This failure to apply finasteride is not attributable to toxicity such as sexual side effects but rather to a concern over high-grade prostate cancer and a lack of confidence in the importance of the clinical observations (4, 5). Is this reluctance to apply finasteride justified Do recent PCPT publications, including two in this issue of the journal, provide sufficient data to alter the recommendations and guide future prevention research
PURPOSE: Improvement in the cost-effectiveness of chemoprevention for prostate cancer could be realized through the identification of patients at higher risk. We estimated the cost-effectiveness of prostate cancer chemoprevention across risk groups defined by family history and number of risk alleles, and the cost-effectiveness of targeting chemoprevention to higher risk groups. MATERIALS AND METHODS: We developed a probabilistic Markov model to estimate costs, survival and quality adjusted survival across risk groups for patients receiving or not receiving chemoprevention with finasteride. The model uses data from national cancer registries, online sources and the medical literature. RESULTS: The incremental cost-effectiveness of 25 years of chemoprevention with finasteride in patients 50 years old was an estimated $89,300 per quality adjusted life-year (95% CI $58,800-$149,800), assuming finasteride decreased all grades of prostate cancer by 24.8%. Among patients with a positive family history (without genetic testing) chemoprevention provided 1 additional quality adjusted life-year at a cost of $64,200. Among patients with a negative family history at $400 per person tested, the cost-effectiveness of genetically targeted chemoprevention ranged from $98,100 per quality adjusted life-year when limiting finasteride to individuals with 14 or more risk alleles, to $103,200 per quality adjusted life-year when including those with 8 or more risk alleles. CONCLUSIONS: Although there are small differences in the cost-effectiveness of genetically targeted chemoprevention strategies in patients with a negative family history, genetic testing could reduce total expenditures if used to target chemoprevention for higher risk groups. 781b155fdc