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.
Highlights
Detection of breast cancer (BC) reduces mortality and may improve quality of life for most of the women diagnosed early by mammographic exams [1]
In 2005 the Institute of Medicine (IOM) identified that personalized screening was crucial to improving the early detection of breast cancer [7]
With an annual discount rate of 3% for every 2,000 women screened, the risk-based strategy Q5074-Q5074-T5074A5074 would extend about the same number of lives (4) as the uniform biennial exams in the 50–69 age interval (B5069) strategy but would avoid 1.5 overdiagnosed cases, 97 False positive (FP) mammograms and would save 250,000 euros
Summary
Detection of breast cancer (BC) reduces mortality and may improve quality of life for most of the women diagnosed early by mammographic exams [1]. The European guidelines recommend offering mammography screening to women aged 50–69 every two years [6] This one-size-fits-all or uniform paradigm is starting to shift toward personalizing screening strategies based on breast cancer risk. Schousboe et al [8], using a Markov microsimulation model, found that the costeffectiveness of screening mammography depended on a woman’s age, breast density, family history, and history of breast biopsy. Based on their results, mammography every two years was costeffective for women aged 40 to years with relatively high breast density or additional risk factors for breast cancer. Mammography every three to four years was cost-effective for women aged to 79 years with low breast density and no other risk factors. van Ravesteyn et al [9], using different microsimulation models, determined that women aged 40 to years with a twofold increase in risk have similar harm-benefit ratios for biennial screening mammography as average-risk women aged to 74 years
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