Breast cancer screening programme in China: does one size fit all? A cost-effectiveness analysis based on a Markov model

Abstract

BackgroundIn China, breast cancer is the most frequently diagnosed cancer in women. Marked disparities between urban and rural populations have been reported for breast cancer incidence and survival. In 2009, China launched a breast cancer screening programme for women living in rural areas who were aged 35–64 years and at average risk. The programme used ultrasound combined with clinical breast examination as the primary screening tool. In 2012, breast cancer screening was done by use of ultrasound, and was followed by mammography among women living in urban areas aged 40–69 years, who were high risk and were identified through risk assessment questionnaires. To date, economic evidence is still scarce. This study aimed to analyse the cost-effectiveness of breast cancer screening compared with no screening among women in rural and urban China. MethodsWe developed a Markov model to estimate the lifetime costs and effects, from a societal perspective, for the general population-based cohorts, both in urban China with high incidence of breast cancer and rural China with low incidence of breast cancer. Analyses were done for women in rural areas aged 35 years and women in urban areas aged 40 years. Women who were asymptomatic in the intervention arm were screened every 3 years. Breast cancer in the non-screening arm could only be diagnosed on presentation of symptoms. The main outcome measure was cost per quality-adjusted life-year (QALY) gained with a 3% annual discount. Parameter uncertainty was explored using one-way and probabilistic sensitivity analyses. FindingsCompared with no screening, the rural breast cancer screening programme cost US$186·72 more and led to a loss of 0·20 QALYs because of disutility from false positives. Breast cancer screening among women in rural China is more expensive, with an incremental cost-effectiveness ratio (ICER) of $-916 per QALY, compared with no screening. In urban areas, the breast cancer screening programme cost $84·99 and gained 0·01 QALYs, with an ICER of $6671 per QALY, well below the willingness-to-pay threshold of $23 050 per QALY at three times GDP per capita (2014) in China. The results are shown to be robust through the sensitivity analyses. InterpretationIn a rural setting, which has low breast cancer incidence, screening for asymptomatic disease among the general population using current screening tools is not cost-effective. Priority should be given to ensure that women who are symptomatic have access to diagnosis and treatment at an early stage. In urban China, a high-risk population-based screening method for breast cancer is very likely to be cost-effective compared with no screening. FundingNational Natural Science Foundation of China (71273016 and 71673004).