Cost-effectiveness and harm-benefit analyses of risk-based screening strategies for breast cancer

Abstract

The one-size-fits-all paradigm in organized screening of breast cancer is shifting towards a personalized approach. The present study has two objectives: 1) To perform an economic evaluation and to assess the harm-benefit ratios of screening strategies that vary in their intensity and interval ages based on breast cancer risk; and 2) To estimate the gain in terms of cost and harm reductions using risk-based screening with respect to the usual practice. We used a probabilistic model and input data from Spanish population registries and screening programs, as well as from clinical studies, to estimate the benefit, harm, and costs over time of 2,624 screening strategies, uniform or risk-based. We defined four risk groups, low, moderate-low, moderate-high and high, based on breast density, family history of breast cancer and personal history of breast biopsy. The risk-based strategies were obtained combining the exam periodicity (annual, biennial, triennial and quinquennial), the starting ages (40, 45 and 50 years) and the ending ages (69 and 74 years) in the four risk groups. Incremental cost-effectiveness and harm-benefit ratios were used to select the optimal strategies. Compared to risk-based strategies, the uniform ones result in a much lower benefit for a specific cost. Reductions close to 10% in costs and higher than 20% in false-positive results and overdiagnosed cases were obtained for risk-based strategies. Optimal screening is characterized by quinquennial or triennial periodicities for the low or moderate risk-groups and annual periodicity for the high-risk group. Risk-based strategies can reduce harm and costs. It is necessary to develop accurate measures of individual risk and to work on how to implement risk-based screening strategies.

Figure 1. Cost-effectiveness and harm-benefit analyses for 2,625 early detection strategies.

Effect measured in lives extended. Dots represent specific screening strategies. Results obtained with an annual discount of 3%. •: uniform B5069; ▪: uniform B4574. ▴: risk-based Q5074-Q5074-Q4574-A4574; ▾: risk-based Q5074-Q5074-T5074-A5074. ◂: risk-based T5069-B5074-A5074-A5074; ▸: risk-based T5074-T5074-A4574-A4574. Exams periodicities: A = annual, B = biennial, T = triennial, Q = quinquennial. The first two numbers refer to the age at starting the exams and the last two numbers refer to the age at the last exam. In the risk-based strategies, the four strings correspond to the Low, Medium-Low, Medium-High and High risk groups, respectively.

Cost-effectiveness and harm-benefit analyses for 2,625 early detection strategies.

Effect measured in quality-adjusted life years. Dots represent specific screening strategies. Results obtained with an annual discount of 3%. •: uniform B5069; ▪: uniform B4574. ▴: risk-based Q5069-Q4574-Q4574-A4574; ▾: risk-based Q5069-Q4574-Q4574-A4074. ◂: risk-based Q5074-Q5074-A4074-A4074; ▸: risk-based Q4574-Q4574-A4574-A4074. Exams periodicities: A = annual, B = biennial, T = triennial, Q = quinquennial. The first two numbers refer to the age at starting the exams and the last two numbers refer to the age at the last exam. In the risk-based strategies, the four strings correspond to the Low, Medium-Low, Medium-High and High risk groups, respectively.