Cost-effectiveness of early detection of breast cancer in Catalonia (Spain)

Misericordia Carles,Francesc Cots,Xavier Castells,Aleix Gregori,Ester Vilaprinyo,Rubén Román,Roger Pla,Francesc Macià,Montserrat Rue,Maria Sala

doi:10.1186/1471-2407-11-192

Abstract

BackgroundBreast cancer (BC) causes more deaths than any other cancer among women in Catalonia. Early detection has contributed to the observed decline in BC mortality. However, there is debate on the optimal screening strategy. We performed an economic evaluation of 20 screening strategies taking into account the cost over time of screening and subsequent medical costs, including diagnostic confirmation, initial treatment, follow-up and advanced care.MethodsWe used a probabilistic model to estimate the effect and costs over time of each scenario. The effect was measured as years of life (YL), quality-adjusted life years (QALY), and lives extended (LE). Costs of screening and treatment were obtained from the Early Detection Program and hospital databases of the IMAS-Hospital del Mar in Barcelona. The incremental cost-effectiveness ratio (ICER) was used to compare the relative costs and outcomes of different scenarios.ResultsStrategies that start at ages 40 or 45 and end at 69 predominate when the effect is measured as YL or QALYs. Biennial strategies 50-69, 45-69 or annual 45-69, 40-69 and 40-74 were selected as cost-effective for both effect measures (YL or QALYs). The ICER increases considerably when moving from biennial to annual scenarios. Moving from no screening to biennial 50-69 years represented an ICER of 4,469€ per QALY.ConclusionsA reduced number of screening strategies have been selected for consideration by researchers, decision makers and policy planners. Mathematical models are useful to assess the impact and costs of BC screening in a specific geographical area.

Highlights

Breast cancer (BC) causes more deaths than any other cancer among women in Catalonia
The assumptions of the Lee and Zelen (LZ) model are (1) a four-state progressive disease in which a subject may be in a disease-free state (S0), preclinical disease state (Sp: capable of being diagnosed by a special exam), clinical state (Sc: diagnosis by symptomatic detection), and a death from BC state (Sdbc); (2) age-dependent transitions into the different states; (3) age-dependent examination sensitivity; (4) age-dependent sojourn times in each state; and (5) exam-diagnosed cases have a stage-shift in the direction of more favorable prognosis relative to the distribution of stages in symptomatic detection
We considered a loss of quality-adjusted life years (QALY) due to the anxiety derived from the screening mammogram itself (7 days at 25% of the healthy state) and from a false positive result (25 days at 25% of the healthy state)

Summary

Introduction

Breast cancer (BC) causes more deaths than any other cancer among women in Catalonia. Detection has contributed to the observed decline in BC mortality. There is debate on the optimal screening strategy. We performed an economic evaluation of 20 screening strategies taking into account the cost over time of screening and subsequent medical costs, including diagnostic confirmation, initial treatment, followup and advanced care. In Catalonia (Spain), as in the majority of Western countries, breast cancer (BC) is the cancer with the highest incidence among women (almost 1/3 of all malignant neoplasms). Detection and adjuvant treatments have contributed to the observed decline in BC mortality since the 1990s. There is debate over the optimal screening strategy, including frequency and starting and ending ages. In the USA, BC drugs are the second biggest category of all pharmaceutical sales, growing at double the overall

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