***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND The comparative effectiveness of treatments for prostate cancer that is detected by prostate-specific antigen ( PSA ) testing remains uncertain . METHODS We compared active monitoring , radical prostatectomy , and external-beam radiotherapy for the treatment of clinical ly localized prostate cancer . Between 1999 and 2009 , a total of 82,429 men 50 to 69 years of age received a PSA test ; 2664 received a diagnosis of localized prostate cancer , and 1643 agreed to undergo r and omization to active monitoring ( 545 men ) , surgery ( 553 ) , or radiotherapy ( 545 ) . The primary outcome was prostate-cancer mortality at a median of 10 years of follow-up . Secondary outcomes included the rates of disease progression , metastases , and all-cause deaths . RESULTS There were 17 prostate-cancer-specific deaths overall : 8 in the active-monitoring group ( 1.5 deaths per 1000 person-years ; 95 % confidence interval [ CI ] , 0.7 to 3.0 ) , 5 in the surgery group ( 0.9 per 1000 person-years ; 95 % CI , 0.4 to 2.2 ) , and 4 in the radiotherapy group ( 0.7 per 1000 person-years ; 95 % CI , 0.3 to 2.0 ) ; the difference among the groups was not significant ( P=0.48 for the overall comparison ) . In addition , no significant difference was seen among the groups in the number of deaths from any cause ( 169 deaths overall ; P=0.87 for the comparison among the three groups ) . Metastases developed in more men in the active-monitoring group ( 33 men ; 6.3 events per 1000 person-years ; 95 % CI , 4.5 to 8.8 ) than in the surgery group ( 13 men ; 2.4 per 1000 person-years ; 95 % CI , 1.4 to 4.2 ) or the radiotherapy group ( 16 men ; 3.0 per 1000 person-years ; 95 % CI , 1.9 to 4.9 ) ( P=0.004 for the overall comparison ) . Higher rates of disease progression were seen in the active-monitoring group ( 112 men ; 22.9 events per 1000 person-years ; 95 % CI , 19.0 to 27.5 ) than in the surgery group ( 46 men ; 8.9 events per 1000 person-years ; 95 % CI , 6.7 to 11.9 ) or the radiotherapy group ( 46 men ; 9.0 events per 1000 person-years ; 95 % CI , 6.7 to 12.0 ) ( P<0.001 for the overall comparison ) . CONCLUSIONS At a median of 10 years , prostate-cancer-specific mortality was low irrespective of the treatment assigned , with no significant difference among treatments . Surgery and radiotherapy were associated with lower incidences of disease progression and metastases than was active monitoring . ( Funded by the National Institute for Health Research ; ProtecT Current Controlled Trials number , IS RCT N20141297 ; Clinical Trials.gov number , NCT02044172 . ) BACKGROUND The European R and omised study of Screening for Prostate Cancer ( ERSPC ) has shown significant reductions in prostate cancer mortality after 9 years and 11 years of follow-up , but screening is controversial because of adverse events such as overdiagnosis . We provide up date d results of mortality from prostate cancer with follow-up to 2010 , with analyses truncated at 9 , 11 , and 13 years . METHODS ERSPC is a multicentre , r and omised trial with a predefined central ised data base , analysis plan , and core age group ( 55 - 69 years ) , which assesses prostate-specific antigen ( PSA ) testing in eight European countries . Eligible men aged 50 - 74 years were identified from population registries and r and omly assigned by computer generated r and om numbers to screening or no intervention ( control ) . Investigators were masked to group allocation . The primary outcome was prostate cancer mortality in the core age group . Analysis was by intention to treat . We did a secondary analysis that corrected for selection bias due to non-participation . Only incidence and no mortality data at 9 years ' follow-up are reported for the French centres . This study is registered with Current Controlled Trials , number IS RCT N49127736 . FINDINGS With data truncated at 13 years of follow-up , 7408 prostate cancer cases were diagnosed in the intervention group and 6107 cases in the control group .  The rate ratio of prostate cancer incidence between the intervention and control groups was 1·91 ( 95 % CI 1·83 - 1·99 ) after 9 years ( 1·64 [ 1·58 - 1·69 ] including France ) , 1·66 ( 1·60 - 1·73 ) after 11 years , and 1·57 ( 1·51 - 1·62 ) after 13 years . The rate ratio of prostate cancer mortality was 0·85 ( 0·70 - 1·03 ) after 9 years , 0·78 ( 0·66 - 0·91 ) after 11 years , and 0·79 ( 0·69 - 0·91 ) at 13 years . The absolute risk reduction of death from prostate cancer at 13 years was 0·11 per 1000 person-years or 1·28 per 1000 men r and omised , which is equivalent to one prostate cancer death averted per 781 ( 95 % CI 490 - 1929 ) men invited for screening or one per 27 ( 17 - 66 ) additional prostate cancer detected . After adjustment for non-participation , the rate ratio of prostate cancer mortality in men screened was 0·73 ( 95 % CI 0·61 - 0·88 ) . INTERPRETATION In this up date the ERSPC confirms a substantial reduction in prostate cancer mortality attributable to testing of PSA , with a substantially increased absolute effect at 13 years compared with findings after 9 and 11 years . Despite our findings , further quantification of harms and their reduction are still considered a prerequisite for the introduction of populated-based screening . FUNDING Each centre had its own funding responsibility Prostate-specific antigen ( PSA ) screening for prostate cancer may reduce mortality , but it incurs considerable risk of over diagnosis and potential harm to quality of life . Our objective was to evaluate the cost-effectiveness of PSA screening , with and without adjustment for quality of life , for the British Columbia ( BC ) population . We adapted an existing natural history model using BC incidence , treatment , cost and mortality patterns . The modeled mortality benefit of screening derives from a stage-shift mechanism , assuming mortality reduction consistent with the European Study of R and omized Screening for Prostate Cancer . The model projected outcomes for 40-year-old men under 14 combinations of screening ages and frequencies . Cost and utility estimates were explored with deterministic sensitivity analysis . The incremental cost-effectiveness of regular screening ranged from $ 36,300/LYG , for screening every four years from ages 55 to 69 years , to $ 588,300/LYG , for screening every two years from ages 40 to 74 years . The marginal benefits of increasing screening frequency to 2 years or starting screening at age 40 years were small and came at significant cost . After utility adjustment , all screening strategies result ed in a loss of quality -adjusted life years ( QALYs ) ; however , this result was very sensitive to utility estimates . Plausible outcomes under a range of screening strategies inform discussion of prostate cancer screening policy in BC and similar jurisdictions . Screening may be cost-effective , but the sensitivity of results to utility values suggests individual preferences for quality versus quantity of life should be a key consideration OBJECTIVES To apply the most recent evidence from r and omised trials of prostate-specific antigen ( PSA ) screening and explore the potential value of risk assessment s to guide the use of PSA screening in practice . DESIGN A decision model that incorporated a Markov process was developed in 2012 to estimate the net benefit and cost of PSA screening versus no screening as a function of baseline risk . MAIN OUTCOME MEASURES Quality -adjusted life-2013s ( QALYs ) and costs . RESULTS The harms of screening outweighed the benefits under a number of plausible scenarios . Conclusions were sensitive to the estimated quality -of-life impacts of prostate cancer treatment as well as the incidence of cancers not detected by screening tests ( poorer prognosis ) and those that were detected by screening tests ( better prognosis ) . The base-case incremental cost-effectiveness ratio of PSA screening was $ 168,611 per QALY for men with average risk , $ 73,452 per QALY for men with two times the average risk , and $ 22,938 [ corrected ] per QALY for men with five times the average risk . CONCLUSIONS PSA screening was not found to be cost-effective for men at an average-to-high risk of prostate cancer , but may be cost-effective for men at very high risk . Inexpensive approaches for identifying men at very high risk are needed , as is further research on the size of clinical benefit of early detection in this population . The potential for the costs of risk assessment to be offset by reduced costs of PSA screening also warrants investigation BACKGROUND The effect of screening with prostate-specific-antigen ( PSA ) testing and digital rectal examination on the rate of death from prostate cancer is unknown . This is the first report from the Prostate , Lung , Colorectal , and Ovarian ( PLCO ) Cancer Screening Trial on prostate-cancer mortality . METHODS From 1993 through 2001 , we r and omly assigned 76,693 men at 10 U.S. study centers to receive either annual screening ( 38,343 subjects ) or usual care as the control ( 38,350 subjects ) . Men in the screening group were offered annual PSA testing for 6 years and digital rectal examination for 4 years . The subjects and health care providers received the results and decided on the type of follow-up evaluation . Usual care sometimes included screening , as some organizations have recommended . The numbers of all cancers and deaths and causes of death were ascertained . RESULTS In the screening group , rates of compliance were 85 % for PSA testing and 86 % for digital rectal examination . Rates of screening in the control group increased from 40 % in the first year to 52 % in the sixth year for PSA testing and ranged from 41 to 46 % for digital rectal examination . After 7 years of follow-up , the incidence of prostate cancer per 10,000 person-years was 116 ( 2820 cancers ) in the screening group and 95 ( 2322 cancers ) in the control group ( rate ratio , 1.22 ; 95 % confidence interval [ CI ] , 1.16 to 1.29 ) . The incidence of death per 10,000 person-years was 2.0 ( 50 deaths ) in the screening group and 1.7 ( 44 deaths ) in the control group ( rate ratio , 1.13 ; 95 % CI , 0.75 to 1.70 ) . The data at 10 years were 67 % complete and consistent with these overall findings . CONCLUSIONS After 7 to 10 years of follow-up , the rate of death from prostate cancer was very low and did not differ significantly between the two study groups . ( Clinical Trials.gov number , NCT00002540 . PURPOSE Preliminary results of the European R and omized Study of Screening for Prostate Cancer showed a decrease in prostate cancer specific mortality associated with prostate specific antigen screening . We evaluated the cost-effectiveness of prostate specific antigen screening using data from the European R and omized Study of Screening for Prostate Cancer protocol when extrapolated to the United States . MATERIAL S AND METHODS We used previously reported Surveillance , Epidemiology and End Results -Medicare data and a nationwide sample of employer provided estimates of costs of care for patients with prostate cancer . The European data were used in accordance with the study protocol to determine the costs and cost-effectiveness of prostate specific antigen screening . RESULTS The lifetime cost of screening with prostate specific antigen , evaluating abnormal prostate specific antigen and treating identified prostate cancer to prevent 1 death from prostate cancer was $ 5,227,306 based on the European findings and extrapolated to the United States . If screening achieved a similar decrease in overall mortality as the decrease in prostate cancer specific mortality in the European study , such intervention would cost $ 262,758 per life-year saved . Prostate specific antigen screening reported in the European study would become cost effective when the lifelong treatment costs were below $ 1,868 per life-year , or when the number needed to treat was lowered to 21 or fewer men . CONCLUSIONS The lifelong costs of screening protocol s are determined by the cost of treatment with an insignificant contribution from screening costs . We established a model that predicts the minimal requirements that would make screening a cost-effective measure for population based implementation BACKGROUND The results of the European R and omized Study of Screening for Prostate Cancer ( ERSPC ) trial showed a statistically significant 29 % prostate cancer mort 
    Output:
    
Model pathways to reflect cancer progression varied widely , Gleason grade was not always considered and clinical verification was rarely outlined .
Conclusion The cost-effectiveness of prostate cancer screening is unclear .
There was no consensus on the optimal model type or approach to model prostate cancer progression .
Due to limited data availability , individual patient-level modelling is unlikely to increase the accuracy of cost-effectiveness results compared with cohort-level modelling , but is more suitable when assessing adaptive screening strategies .