Shifting breast cancer surveillance from current hospital setting to a community based setting: a cost-effectiveness study

Kelly M De Ligt,Annemieke Witteveen,Lotte M G Steuten,Sabine Siesling

doi:10.1186/s12885-018-3992-7

Abstract

BackgroundThis study explores the effectiveness and cost-effectiveness of surveillance after breast cancer treatment provided in a hospital-setting versus surveillance embedded in the community-based National Breast Cancer Screening Program (NBCSP).MethodsUsing a decision tree, strategies were compared on effectiveness and costs from a healthcare perspective over a 5-year time horizon. Women aged 50–75 without distant metastases that underwent breast conserving surgery in 2003–2006 were selected from the Netherlands Cancer Registry (n = 14,093). Key input parameters were mammography sensitivity and specificity, risk of loco regional recurrence (LRR), and direct healthcare costs. Primary outcome measure was the proportion true test results (TTR), expressed as the positive and negative predictive value (PPV, NPV). The incremental cost-effectiveness ratio (ICER) is defined as incremental costs per TTR forgone.ResultsFor the NBCSP-strategy, 13,534 TTR (8 positive; 13,526 negative), and 12,923 TTR (387 positive; 12,536 negative) were found for low and high risks respectively. For the hospital-based strategy, 26,663 TTR (13 positive; 26,650 negative) and 24,883 TTR (440 positive; 24,443 negative) were found for low and high risks respectively. For low risks, the PPV and NPV for the NBCSP-based strategy were 3.31% and 99.88%, and 2.74% and 99.95% for the hospital strategy respectively. For high risks, the PPV and NPV for the NBCSP-based strategy were 64.10% and 98.87%, and 50.98% and 99.71% for the hospital-based strategy respectively. Total expected costs of the NBCSP-based strategy were lower than for the hospital-based strategy (low risk: €1,271,666 NBCSP vs €2,698,302 hospital; high risk: €6,939,813 NBCSP vs €7,450,150 hospital), rendering ICERs that indicate cost savings of €109 (95%CI €95–€127) (low risk) and €43 (95%CI €39–€56) (high risk) per TTR forgone.ConclusionDespite expected cost-savings of over 50% in the NBCSP-based strategy, it is nearly 50% lower accurate than the hospital-based strategy, compromising the goal of early detection of LRR to an extent that is unlikely to be acceptable.

Highlights

This study explores the effectiveness and cost-effectiveness of surveillance after breast cancer treatment provided in a hospital-setting versus surveillance embedded in the community-based National Breast Cancer Screening Program (NBCSP)
While women feel reassured by attending the breast cancer clinic [11], within a hospital setting no clinical benefits have been demonstrated for highintensity, longer duration or high-frequency surveillance schemes compared to schemes with lower resource demands
Both strategies are compared from the second year on: during the first year the surveillance aims for cancer detection, and addresses potential post-treatment complications of physical and psychological nature [5], which can only be provided at a hospital and not at the NBCSP, and is not taken into account in this study

Summary

Introduction

This study explores the effectiveness and cost-effectiveness of surveillance after breast cancer treatment provided in a hospital-setting versus surveillance embedded in the community-based National Breast Cancer Screening Program (NBCSP). In the Dutch national guideline on breast cancer (NABON guideline) surveillance schemes consist of physical examination and annual mammography and take place in the hospital for five years after treatment [5]. These schemes are comparable to surveillance schemes in other countries, such as the United Kingdom [6], Australia [7] and the United States [8]. Screening is done by mammography and takes place in mobile screening busses that call on communities across the country [5, 17]

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