Cost-effectiveness of breast cancer control strategies in Central America: the cases of Costa Rica and Mexico.

Laurens M Niëns,Sten G Zelle,Blanca Rosa Hidalgo Balarezo,Gustavo Rivera Peña,Frans F H Rutten,Cristina Gutiérrez-Delgado,Erick Rodriguez Steller

doi:10.1371/journal.pone.0095836

Abstract

This paper reports the most cost-effective policy options to support and improve breast cancer control in Costa Rica and Mexico. Total costs and effects of breast cancer interventions were estimated using the health care perspective and WHO-CHOICE methodology. Effects were measured in disability-adjusted life years (DALYs) averted. Costs were assessed in 2009 United States Dollars (US$). To the extent available, analyses were based on locally obtained data. In Costa Rica, the current strategy of treating breast cancer in stages I to IV at a 80% coverage level seems to be the most cost-effective with an incremental cost-effectiveness ratio (ICER) of US$4,739 per DALY averted. At a coverage level of 95%, biennial clinical breast examination (CBE) screening could improve Costa Rica's population health twofold, and can still be considered very cost-effective (ICER US$5,964/DALY). For Mexico, our results indicate that at 95% coverage a mass-media awareness raising program (MAR) could be the most cost-effective (ICER US$5,021/DALY). If more resources are available in Mexico, biennial mammography screening for women 50–70 yrs (ICER US$12,718/DALY), adding trastuzumab (ICER US$13,994/DALY) or screening women 40–70 yrs biennially plus trastuzumab (ICER US$17,115/DALY) are less cost-effective options. We recommend both Costa Rica and Mexico to engage in MAR, CBE or mammography screening programs, depending on their budget. The results of this study should be interpreted with caution however, as the evidence on the intervention effectiveness is uncertain. Also, these programs require several organizational, budgetary and human resources, and the accessibility of breast cancer diagnostic, referral, treatment and palliative care facilities should be improved simultaneously. A gradual implementation of early detection programs should give the respective Ministries of Health the time to negotiate the required budget, train the required human resources and understand possible socioeconomic barriers.

Highlights

Due to population ageing and changing lifestyles in low-andmiddle countries (LMICs), breast cancer incidence rates are increasing [1,2]
In expanding Costa Rica’s breast cancer services, our analysis shows that treatment of all stages plus a clinical breast examination (CBE) screening program targeting women between 40 and 70 years of age (I–IV+ CBE (40–70)) is the best option
Our results show that media Awareness Raising (MAR) averts 32,908 disability-adjusted life years (DALYs) per year at a yearly cost of Unit cost per patient (US$)165 million, which leads to an average cost-effectiveness ratio (ACER) of US$5,021 per DALY averted

Summary

Introduction

Due to population ageing and changing lifestyles in low-andmiddle countries (LMICs), breast cancer incidence rates are increasing [1,2]. Given the organizational and financial constraints faced by the health systems in LMICs the majority of breast cancers are diagnosed at late stages [3]. The majority of breast cancer deaths occur in LMICs [4,5]. The World Health Organization (WHO) states that early detection and implementation of cost-effective interventions should be a priority in LMICs [6]. In an attempt to support LMICs with breast cancer control, the Susan G. Komen for the cure foundation provided a grant to investigate the cost-effectiveness of several breast cancer control interventions in 7 LMICs (Brazil, Colombia, Costa-Rica, Ghana, India, Mexico and Peru) to a consortium of the WHO, Erasmus University Rotterdam (EUR) and Radboud University Nijmegen Medical Center (RUNMC). Cost-effectiveness analyses may support governments in deciding how to spend scarce resources in health care most efficiently

Methods

Results

Conclusion