To understand why this matters, it helps to look at the diagnostic dilemma that has haunted prostate cancer medicine for decades. PSA is a protein produced by the prostate, and elevated levels can signal cancer, but they can also signal benign enlargement or inflammation. When a man’s PSA falls in the diagnostic gray zone of 4 to 10 nanograms per milliliter, clinicians face genuine uncertainty: the majority of these men do not have clinically significant cancer, yet the current pathway often sends many of them toward magnetic resonance imaging and, if the scan looks suspicious, toward needle biopsy. Biopsies are invasive, uncomfortable, carry a risk of bleeding and infection, and impose substantial costs on health systems. Every unnecessary biopsy avoided is a small victory for both patients and budgets.

The Prostate Health Index was designed specifically to sharpen this gray zone. It is a mathematical combination of three different forms of PSA, including a precursor form called p2PSA, yielding a single score that better discriminates aggressive cancer from benign conditions. In the pathway modeled by the Chinese team, men with PSA between 4 and 10 ng/mL would first receive a PHI test. Only those whose PHI exceeded a chosen cutoff would proceed to MRI, and only those with a sufficiently suspicious MRI result, graded PI-RADS 3 or higher on the standard Prostate Imaging Reporting and Data System, would undergo biopsy. This creates a layered funnel, with each filter designed to spare men without clinically significant disease from the more invasive and expensive steps downstream.

The study’s engine was a Markov microsimulation model, a technique that simulates the medical journey of individual hypothetical patients year by year as they move between health states such as healthy, screened, diagnosed, treated, and deceased. Microsimulation is particularly well suited to screening questions because it can track heterogeneity across a population: different men develop cancer at different rates, progress at different speeds, and respond differently to detection and treatment. By comparing two strategies head to head, the standard PSA pathway versus the PHI-augmented pathway, the researchers could tally up costs, quality-adjusted life years (QALYs), biopsies performed, cancers missed, and deaths over a lifetime horizon.

The headline results come from the base-case comparison: a PHI strategy that begins screening at age 50, repeats every two years, and uses a PHI cutoff of 35. Compared with the PSA strategy, this configuration reduced diagnostic costs by $643,398, a 30.1 percent saving, and reduced total costs by $1,115,276, or 6.4 percent, per 10,000 men screened. Most dramatically, it avoided 1,815 unnecessary biopsies, a 62.9 percent reduction. The trade-offs were real but modest: the PHI strategy produced 32 fewer QALYs, missed 6 additional cases of clinically significant prostate cancer, and resulted in 8 additional deaths per 10,000 men. The incremental cost-utility ratio, the extra cost per QALY gained by one strategy over another, came out at $34,852 per QALY, a figure the authors describe as favorable in the Chinese economic context.

That last number deserves unpacking, because it is the hinge on which the entire cost-effectiveness argument turns. Health economists typically judge a intervention’s value by comparing its cost per QALY against a willingness-to-pay threshold, often anchored to a country’s gross domestic product per capita. In China, interventions costing roughly one to three times GDP per capita per QALY are frequently considered good value. At $34,852 per QALY, the PHI strategy sits in a range that most health systems, including China’s rapidly expanding network of public health insurance schemes, could plausibly justify, especially given the enormous downstream savings from avoided biopsies and avoided imaging.

But the study did not stop at a single comparison. One of its most valuable contributions is a systematic exploration of how the three key dial settings, the age at which screening begins, the interval between screening rounds, and the PHI cutoff value, reshape the economics. The findings follow an intuitive logic. Starting screening at older ages, lengthening the intervals between rounds, or raising the PHI cutoff all push costs down and further reduce unnecessary biopsies. The price of that frugality, however, is a rise in missed diagnoses of clinically significant cancer, more deaths, and a loss of health utility. Screening too rarely or too late means cancers that would have been caught early instead progress undetected, and some men pay with their lives.

Within the secondary analyses, two configurations emerged as particularly attractive. Among the scenarios varying screening start age and interval, initiating screening at age 50 with a four-year interval showed favorable cost-effectiveness. Among the cutoff scenarios, a PHI cutoff of 35 performed best. In other words, the sweet spot is not the most aggressive screening schedule but a moderately intensive one: begin at 50, screen every four years rather than every two, and use a cutoff of 35 to decide who advances to MRI. This combination captures most of the biopsy-sparing and cost-saving benefits while keeping the losses in QALYs and the excess cancer deaths to a level the model judges acceptable.

The implications for Chinese health policy are considerable. China’s prostate cancer incidence has been climbing as the population ages and Westernized lifestyles spread, yet the country has no unified national prostate screening program comparable to organized screening efforts for cervical or breast cancer. Opportunistic PSA testing, where it happens at all, generates exactly the kind of overdiagnosis and overtreatment cascade this study set out to quantify. A PHI-based pathway, deployed with the parameters identified here, offers a blueprint for a more disciplined system: fewer men funneled into MRI, far fewer subjected to biopsy, and health dollars freed up for other priorities. Because the analysis was built specifically on Chinese cost data and population characteristics, its conclusions carry more local weight than extrapolations from European or American models.

As with any modeling study, caveats apply. Microsimulation models are only as good as the inputs fed into them, including cancer incidence, test performance, treatment outcomes, and costs, and the authors performed sensitivity analyses to probe how robust their conclusions were to uncertainty in these parameters. Real-world implementation would also raise questions the model cannot fully answer, such as laboratory capacity for p2PSA testing, adherence to screening schedules, and equitable access across urban and rural populations. Still, the study represents a rigorous, locally grounded step toward evidence-based prostate cancer screening policy in China. Its central message is one that health systems worldwide are grappling with: the future of cancer screening lies not in testing more, but in testing smarter, using layered, cost-conscious pathways that reserve invasive procedures for the men who genuinely need them.

Subject of Research: Cost-effectiveness of the Prostate Health Index for prostate cancer screening in Chinese men

Article Title: Economic evaluation of prostate health index for prostate cancer screening and diagnostic pathway in Chinese men by varying screening initiation ages, intervals, and cutoffs

Article References: Yan, T., Su, Z., Zhang, W., Lin, Y., Li, S., Yao, Q., Chen, Z., Dong, Y., Zhou, C., Lei, X., Gong, C., & Zhu, C. (2026). Economic evaluation of prostate health index for prostate cancer screening and diagnostic pathway in Chinese men by varying screening initiation ages, intervals, and cutoffs. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15762-x

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15762-x

Keywords: prostate cancer, Prostate Health Index, PSA, cost-effectiveness, screening, Markov model, MRI, biopsy, QALY, China, health economics, diagnostic pathway