Cost-Effectiveness and Harm-Benefit Analyses of Risk-Based Screening Strategies for Breast Cancer

Abstract

Interval Cancer (INCA) Study Group (alphabetical order): IMIM (Hospital del Mar Medical Research Institute), Barcelona: Jordi Blanch, Xavier Castells, Mercè Comas, Laia Domingo, Francesc Maciè, Juan Martínez, Ana Rodríguez-Arana, Marta Román, Anabel Romero, Maria Sala. General Directorate Public Health and Centre for Public Health Research (CSISP), FISABIO, Valencia: Carmen Alberich, María Casals, Josefa Ibáñez, Amparo Lluch, Inmaculada Martínez, Josefa Miranda, Javier Morales, Dolores Salas, Ana Torrella. Galician Breast Cancer Screening Program, Xunta de Galicia: Raquel Almazán, Miguel Conde, Montserrat Corujo, Ana Belén Fernández, Joaquín Mosquera, Alicia Sarandeses, Manuel Vázquez, Raquel Zubizarreta. General Directorate of Health Care Programmes. Canary Islands Health Service: Teresa Barata, Isabel Díez de la Lastra, Juana María Reyes. Basque Country Breast Cancer Screening Program. Osakidetza: Arantza Otegi, Garbine Sarriugarte. Corporació Sanitària Parc Taulí, Sabadell: Marisa Baré, Núria Torà. Hospital Santa Caterina, Girona: Joana Ferrer, Francesc Castanyer, Gemma Renart. Epidemiology Unit and Girona Cancer Registry; and University of Girona: Rafael Marcos-Gragera, Montserrat Puig-Vives. Universitat de Lleida-IRBLleida: Carles Forne´, Montserrat Martínez-Alonso, Albert Roso, Montserrat Rué, Ester Vilaprinyó. Universitat Rovira i Virgili, Tarragona: Misericordia Carles, Aleix Gregori, Marí José Pérez, Roger Pla

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

This study was funded by grants PS09/01340 and PS09/01153 from the Health Research Fund (Fondo de Investigacio´n Sanitaria) of the Spanish Ministry of Health. The authors thank the Breast Cancer Surveillance Consortium and the funding that the BCSC received from the National Cancer Institute (U01CA63740, U01CA86076, U01CA86082, U01CA63736, U01CA70013, U01CA69976, U01CA63731, U01CA70040, and HHSN261201100031C)