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. 2025 Dec 24.
doi: 10.1007/s00330-025-12195-8. Online ahead of print.

Cost-effectiveness of contrast-enhanced mammography compared to conventional imaging in the work-up after screening (RACER trial)

Lidewij M F H Neeter  1   2 , Marc B I Lobbes  3   4   5 , Katya M Duvivier  6 , H P J Frank Raat  7 , Marjolein L Smidt  8 , Joachim E Wildberger  1   9 , Brigitte A B Essers  10
Affiliations

Cost-effectiveness of contrast-enhanced mammography compared to conventional imaging in the work-up after screening (RACER trial)

Lidewij M F H Neeter et al. Eur Radiol. .

Abstract

Objective: The randomised controlled clinical RACER trial studied the diagnostic work-up with contrast-enhanced mammography (CEM) compared to conventional imaging as the primary tool in women recalled from breast cancer screening. This current trial-based economic evaluation was performed from a hospital perspective.

Materials and methods: Cost prices were retrieved from the financial departments of the Maastricht University Medical Centre. Health-related quality of life was measured five times over 18 months using the EQ-5D-5L questionnaire. Cost-utility analysis outcome was expressed as costs per quality-adjusted life year (QALY). Multiple imputation was used for missing data, and non-parametric bootstrap analysis was performed to examine uncertainty in the difference in costs and incremental costs per QALY. Post hoc subgroup analysis was performed per BI-RADS recall score.

Results: Work-up with CEM showed lower total costs of €-117 (95% CI €-254; €+22) compared to conventional imaging. Average imaging costs were significantly lower with CEM (mean difference €-130; 95% CI €-153; €-105). Mean QALY for the CEM group was 1.2034 versus 1.2137 for the control group. Bootstrap analysis showed that 95% of all simulated ICERs were in the quadrants that indicate cost-savings, although 25% of the ICERs showed a small gain in QALY and 70% a small QALY loss. The probability of CEM being cost-effective is 53% at a threshold of €10,000 to accept a QALY loss. In the subgroup of BI-RADS 0 recalls, specifically, this probability is 85%.

Conclusion: CEM as a primary tool in the diagnostic work-up is a cost-effective diagnostic strategy, especially in BI-RADS 0 recalls.

Key points: Question Diagnostic accuracy is similar with contrast-enhanced mammography (CEM) compared to conventional as primary imaging. However, while the work-up is more efficient, is it also a cost-effective strategy? Findings Using CEM as primary imaging tool in the diagnostic work-up of recalls from screening results in lower costs with similar QALY compared to conventional imaging. Clinical relevance In BI-RADS- 0 (low suspicion) recalls, CEM should be used as primary imaging modality instead of conventional imaging. CEM compared to conventional imaging in the work-up of recalled women is cost-effective. In other recalls, CEM should be strongly considered.

Keywords: Cost-benefit analysis; Cost-effectiveness analysis; Early detection of cancer; Health care costs; Mammography.

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Conflict of interest statement

Compliance with ethical standards. Guarantor: The scientific guarantor of this publication is M.L. Conflict of interest: M.L. received research funding from GE Healthcare, Hologic Inc., and Sirius Medical B.V. M.L. received honorary fees for presentations and participation of medical advisory boards from GE Healthcare, Hologic Inc., Sirius Medical B.V., Bayer, Guerbet, and Tromp Medical B.V. J.W. received institutional grants from Abbott, Anaconda Biomed, Asklepios, Bayer, Becton & Dickinson medical, Bentley, Boston, Brainlab, GE Healthcare, Gleamer, Hologic, Inari Medical, Johnson & Johnson, Merit Medical Systems, Nico-Lab, Medtronic, Microvention, Nova Techs, Oldelft Benelux, Ontario Associatino of Radiologists, Penumbra, Philips, Siemens, Stryker, Tajpan Sro. L.N., K.D., F.R., M.S., and B.E. had no conflicts of interest to report. Statistics and biometry: One of the authors (B.E.) has a background in Health Technology Assessment and experience with conducting and analysing trial-based economic evaluations. Informed consent: Written informed consent was obtained from all subjects (patients) in this study. Ethical approval: Institutional Review Board approval was obtained (METC171082/NL62788.068.17). Study subjects or cohorts overlap: The study protocol and clinical outcomes of the RACER trial have already been published and are available via Open Access. Methodology: Prospective Trial-based economic evaluation Multicenter study

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