Background. Prostate cancer (PCa) is the second most commonly diagnosed cancer, and the sixth most common killer among men worldwide (Aubry et al., 2013). This research was motivated by the fact that PCa screening continues to be a controversial topic in the Kazakh medical community. This study aimed at description of how newly diagnosed PCa patients are managed in Pavlodar region of the Kazakhstan Republic and at presentation of a budget impact analysis (BIA) for PCa screening program. Also, we aimed to provide a comparative analysis of pricing system on medical services applied in both private and public healthcare sectors of the Kazakhstan Republic. Methods. New cases of PCa have been retrospectively analyzed for the period from January 2013 to December 2017 based on the information obtained from information system “Policlinic” maintained by the Pavlodar regional branch of the Republican Center for Electronic Health and from Cancer Registry of Pavlodar Regional Oncology Center. All data were analyzed with the help of SPSS 20.0 software. Results. The mean age of PCa patients was 68.34 years (SD = 8.559). The government of Kazakhstan invested 20,437,000 KZT (Kazakhstani tenge) in 2017 equivalently 61,188 USD—to fund a pilot study for examination of 9638 men. From 2013 to 2017, out of 49,334 men residing in Pavlodar region of Kazakhstan 1,248 men were diagnosed with prostate diseases, including 130 PCa cases. The PCa detection rate was equal to two cases per month. Only 22.8% of all PCa cases identified in the region within specified time period were revealed as a result of the government-funded PCa screening program. The average prostate cancer detection rate among the target group of Pavlodar region within the period of 5 years was equal to 0.23%. Conclusion. Based on the fact that the PCa screening program failed to enable adequate detection of new PCa cases, we would not recommend to continue this type of screening unless it is undergone careful revision and replanning.
Prostate cancer (PCa) is the second most commonly diagnosed cancer, and the sixth most common killer among men worldwide . With an estimated annual incidence of 903,500 cases per year, PCa causes more than 250,000 deaths annually [2–4]. The incidence of PCa varies starkly across different regions. For example, it is well-known that the incidence rate of PCa is significantly lower in Asia than in Western countries, and much higher in the developing world than in the developed world . The rates of metastatic disease and deaths from PCa in Asian countries are higher than those in Western countries due to the low exposure rate to screening . PCa mortality rates have steadily decreased over the past 10 years in many countries, including England, Wales, the Czech Republic and the United States, but are increasing in Eastern European countries and in some Asian countries, such as Korea [7–9]. PCa morbidity indicators have also increased over the last several years in Kazakhstan as well , which may be due to introduction of the screening program that started in 2013 .
It is estimated that in the United States alone 1.86 billion USD are spent annually on PSA testing and more than 4 billion USD are spent annually on therapies for PCa . According to 2007–2009 costs of PSA-based PCa screening, the average annual PCa screening cost per beneficiary was 36 USD. The inverse relation between beneficiary’s age and screening cost was established (). Extrapolating the costs of the fee-for-service provided to Medicare beneficiaries (United States’ healthcare for people of over 65) to population nationwide, the annual costs of PCa screening to the program were 447 million USD, including 145 million USD for men aged over 75 years .
Economic evaluation is particularly important for preventive medicine, which holds great potential to improve healthcare, particularly in low- and middle-income countries . Studies evaluating the cost-effectiveness of PSA screening have produced a wide range of results. Despite several model-based evaluations, the robust evidence to suggest cost-effectiveness is lacking . A recent study based in the United States estimated that PSA screening costs 262,758 USD per life-year gained (LYG), or over 5 million USD per death avoided . A systematic review reported that cost-effectiveness is in the range of 12,000 USD /LYG to 5,000 USD /LYG, which suggests that screening is more cost-effective in men aged 50–69 years as compared to men over 70 years of age . Pataky et al. argue that screening for PCa with low frequency PSA testing may be cost-effective when quality of life is not considered, but all developed 14 screening strategies had a net negative effect on the Quality Adjusted Life Years (QALYs) . According to Shin et al. the national Prostate-Specific-Antigen (PSA) screening in South Korea is not cost-effective . Recently, a systematic review on cost-effectiveness of PCa screening was published. Once more, this study concluded that the answer to the question of whether or not screening for prostate cancer is cost-effective remains unclear. According to existing health economics research, population-wide PSA screening is costly and ineffective but still, it may be cost-effective in certain populations .
Studies on the cost-effectiveness of PCa screening are primarily based on developed countries’ data and relatively little is known about developing countries, especially due to the lack of large longitudinal databases . The experience of Kazakhstan is interesting in this respect, since in 2013 the country launched a Prostate Cancer Screening Program which was terminated at the end of 2017. This decision could be partly attributed to the lack of reliable PCa screening system in Kazakhstan. In fact, the results of a recently published study indicate that PSA test is not a reliable method for identification of PCa among Kazakhstani patients as there was a high ratio of false-positive results for this test, which resulted in unnecessary biopsies. This 2017 study also found that the test’s sensitivity is as high as 96.61%, but the specificity is as low as 10.43% . This study aimed at description of how newly diagnosed PCa patients are managed in Pavlodar region of the Kazakhstan Republic and at presentation of a budget impact analysis (BIA) for PCa screening program. Also, we aimed to provide a comparative analysis of pricing system on medical services applied in both private and public healthcare sectors of the Kazakhstan Republic.
2. Materials and Methods
In Kazakhstan, the healthcare system essentially focuses on the provision of primary care. This goes back to the Soviet days, to the Alma-Ata 1978 International Conference on Primary Healthcare, or Health for all, which emphasized the significance of primary care. This conference is famous for the adoption of the so-called Alma-Ata Declaration. Kazakhstan is currently implementing the state program for the development of healthcare system entitled “Densaulyk”, which covers the period of 2016–2019. Based on this program, the government of Kazakhstan pays particular attention to the provision of national screening programs. Concerning PCa screening, it was carried out in the period from 2013 through 2017, and covered 11 out of the 16 country regions. The country introduced government-funded serum PSA testing among men aged 50, 54, 58, 62 and 66 years. In 2013, the pilot PCa screening were initiated in East Kazakhstan, West Kazakhstan, Kyzylorda and Pavlodar regions, as well as in two cities of national significance (Almaty and Astana). In 2014, this effort was extended to Aktobe, Atyrau, Karaganda, Kostanay and North Kazakhstan regions . However, since 2018, the government-funded PCa screening has been stopped due to the expansion of target age groups for breast, cervical and colorectal cancers.
All PCa screening procedures were regulated by the Order of the Ministry of Health “On approval of the Rules for conducting preventive medical examinations of target population groups” of November 2009 (N 685). According to this Order, the target population groups were men aged 50, 54, 58, 62 and 66 years not followed for prostate cancer. The primary healthcare establishments invited all men of appropriate ages by means of direct contact, phone calls or via family members/neighbors to attend the clinic for a PSA blood test. For the PCa screening within 2013–2017, 49,334 agreed to participate. According to the local health plan, in 2017 out of 20,628 men aged 50, 54, 58, 62 and 66 years, only 9,638 men took part in the Prostate Screening Program, which resulted in 46.7% response rate. Besides testing serum PSA levels by means of immunohistochemistry, the PCa screening also involved evaluation of the so-called “Prostate Health Index” (PHI) that was based on measurements of total PSA, free PSA and proPSA. The PSA cut-off for a prostate biopsy was total PSA ≥7.8 ng/ml or PHI ≥25. The actual number of men who had undergone prostate biopsy was not reported.
Pavlodar region was involved in this pilot screening program for PCa within the entire period of its implementation, which equaled five years. The region locates in North-Eastern part of Kazakhstan and has a population of 769,346 people. Of these, 49,334 men were exposed to PCa screening from January 2013 to December 2017 that was organized in primary healthcare centers throughout the region. General practitioners and nurses drove data about participants’ cases into the screening registry. Afterwards, all cancer cases identified were registered in the cancer registry by the staff from the local oncology center. We obtained this dataset and subjected it to retrospective analysis. The dataset included all prostate cancer cases that were diagnosed between January 1, 2013 and December 31, 2017 (code C61, based on the International Classification of Diseases, 10th edition). For economic analysis, we obtained the official financial documents from the Healthcare Department of Pavlodar region. Information about prices on medical services of private sector was analyzed based on the data presented on official websites of health care establishments.
All patients with verified PCa undergo treatment at governments expense. The available treatment options are detailed in the national guidelines “Cancer of the Prostate” that follow recommendations given in Clinical Practice Guidelines of the European Society for Medical Oncology (https://www.esmo.org/Guidelines/Genitourinary-Cancers/Cancer-of-the-Prostate).
2.1. Statistical Analyses
IBM SPSS Statistics version 20.0 was used for all data analyses. We computed the following variables: age, stage of the disease, year of diagnosis, place of residence and PCa cases detected out of screening program. Student’s t-test, Pearson’s chi-square test and one-way analysis of variance were applied to test for the difference. Student’s t-test was used to compare the mean values of continuous variables, like age and residence, while comparison between the mean values of variables like disease stage/year of diagnosis were conducted by the one-way analysis of variance. Chi-squared test was used to compare the categorical or nominal variables. Normally distributed data were expressed as the mean and standard deviation. Differences were considered statistically significant when .
The survey was approved by the Ethical Committee of Semey Medical University, Kazakhstan.
Overall, there were 49,334 men who were screened for PCa within 2013–2017 by means of serum PSA measurement. Of these, 47,234 men had PSA level not exceeding 3.1 ng/ml, in 1,679 men the PSA levels ranged from 3.1 to 7.8 ng/ml, and in 421 men the serum PSA was 7.8 ng/ml and higher. There were 2.5% of men who were diagnosed with benign prostate hyperplasia or prostatis following the subsequent evaluation (Table 1).
Number of patients examined for PSA
Results of PSA test
Free PSA & ProPSA
PHI 25 and above
Number of identified diseases (N40, N41)
Number of identified PCa
2–4 points according to Gleason
5–7 points according to Gleason
8–10 points according to Gleason