Biennial Screening Research Articles

Cost-effectiveness of ColoSTAT for primary colorectal cancer screening in the United States.

e15525 Background: Colorectal cancer (CRC) screening is at the cornerstone of strategies for reducing the mortality, healthcare and societal cost burden of CRC, the third most common cancer in the United States (US). ColoSTAT immunoassay is a simple, highly accurate, minimally invasive blood-based screening test for CRC that will be launched in the US market. Using a de novo decision analytic model, we compared the health benefits and cost-effectiveness of CRC screening with ColoSTAT with current screening offered by private insurers assuming a 5-yearly colonoscopy (COL) or biennial fecal immunochemical test (FIT) for the US population. Methods: For the three screening strategies, the expected number of CRC cases detected, and total screening program cost were estimated using a decision-analytic model based on: published CRC incidence in the US, tests performance characteristics, adherence rates to screening (61% for COL; 46% for FIT) and to diagnostic assessment via COL after a positive FIT or ColoSTAT test (80.4%). The gain in quality-adjusted life year (QALY) associated with every CRC case detected through screening, and confirmed by diagnostic assessment, was estimated by linking US-specific estimates of: CRC deaths by age-subgroups, life expectancies at the time of CRC death, quality of life projections for the general population and reduction in CRC mortality associated with screening. Healthcare cost savings associated with every CRC case detected through screening were estimated based on the distribution of CRC across disease stages by diagnosis method (screening versus symptomatically) and stage-specific CRC treatment costs. Results: Biennial screening with ColoSTAT, compared with 5-yearly COL screening offered by private insurers, is estimated to generate cost savings on screening programs of around $40 million per 100,000 people of screening age (PoSA) per one-off screening. When scaled up to the total US population within screening age covered by private insurance (66%), the estimated cost savings with ColoSTAT exceed $30 billion per one-off screening. The reduction in the number of CRC cases detected would generate a modest loss of 58 discounted QALYs per 100,000 people, that could be mitigated if ColoSTAT were to boost screening uptake. In the context of government-sponsored screening programs, replacing FIT with ColoSTAT is estimated to increase the number of CRC cases detected via screening by 9% (to 50 cases per 100,000 PoSA), assuming an unchanged screening uptake of 46%. At the commonly used value of $100,000 per QALY, this would equate to a discounted benefit of $834,820 per 100,000 PoSA per one-off screening. Conclusions: CRC screening with ColoSTAT as an alternative to COL could result in multi-billion-dollar cost savings to US private insurers while still detecting most CRC cases and generate population-health gains if used as an alternative to FIT in government-sponsored screening programs.

Cost of breast cancer screening in the USA: Comparison of current practice, advocated guidelines, and a personalized risk-based approach.

e18917 Background: Several clinical trials are comparing the safety and efficacy of risk-based and age-based breast cancer screening. This study aimed to estimate the aggregate yearly cost of screening in the USA for 2019 to 2021 and to project cost of four strategies: annual, biennial, hybrid, and the WISDOM (Women Informed to Screen Depending on Measures of risk) clinical trial’s risk-based strategy. An assessment of screening costs under different strategies can inform policy decisions. Methods: Total cost was estimated for each strategy by summing screening and recall cost for eligible women from a national payer perspective. Data from the FDA Mammography Quality Standards Act and Program was used to estimate the number of screening mammograms in 2019 to 2021. Data from the Optum Labs Data Warehouse (OLDW) was used to estimate utilization of 2D and 3D mammograms, MRI and mammogram costs, recall costs and rates. OLDW contains longitudinal de-identified administrative, medical, and pharmacy claims for over 200 million commercial and Medicare Advantage (MA) enrollees and patients. Study subjects were continuously enrolled for approximately three years to capture all encounters. Medicare Advantage claims were used to approximate public payer costs and rates. We assumed 100% adherence to all strategies. The risk-based strategy used a cost of $270 for genetic testing and risk assessment. Probabilistic sensitivity analysis was used to estimate uncertainty in the estimated aggregate cost. One-way deterministic sensitivity analysis was used to determine the impact of each input on the aggregate cost. Results: Median mammogram costs ranged from $139-$360, MRI costs ranged from $545-$2,439, while recall rates ranged from 9.2%-20.9%. The annual cost of screening 50% of eligible women in 2019 was $11.5B ($10.37-13.94B) and cost $77,824 per breast cancer detected. The estimated yearly aggregate cost of screening 100% of eligible women was: $26.71B ($24.61-32.82B) for annual; $18.09B ($16.03-21.16B) for hybrid; $7.57B ($6.97-9.29B) for biennial; and $9.60B ($8.88-11.70B) for risk-based strategies. The estimated average cost per woman screened until 74 years was: $22,315 for annual; $16,552 for hybrid; $4,133 for biennial; and $6,878 for risk-based. The yearly aggregate cost of screening was most sensitive to variations in commercial 3D mammography cost. Conclusions: Biennial and risk-based screening can reduce cost substantially. Risk-based screening reduced cost even with the cost of population genetic testing included while maintaining intensive screening for the highest-risk women. The resources saved can be used to improve screening for women at high-risk of fast-growing disease who are often identified between screens and for improving overall adherence.

Mammographic density and interval cancers in mammographic screening: Moving towards more personalized screening.

The European Society on Breast Imaging has recommended supplemental magnetic resonance imaging (MRI) every two to four years for women with mammographically dense breasts. This may not be feasible in many screening programs. Also, the European Commission Initiative on Breast Cancer suggests not implementing screening with MRI. By analyzing interval cancers and time from screening to diagnosis by density, we present alternative screening strategies for women with dense breasts. Our BreastScreen Norway cohort included 508536 screening examinations, including 3125 screen-detected and 945 interval breast cancers. Time from screening to interval cancer was stratified by density measured by an automated software and classified into Volpara Density Grades (VDGs) 1-4. Examinations with volumetric density ≤3.4% were categorized as VDG1, 3.5%-7.4% as VDG2, 7.5%-15.4% as VDG3, and ≥15.5% as VDG4. Interval cancer rates were also determined by continuous density measures. Median time from screening to interval cancer was 496 (IQR: 391-587) days for VDG1, 500 (IQR: 350-616) for VDG2, 482 (IQR: 309-595) for VDG3 and 427 (IQR: 266-577) for VDG4. A total of 35.9% of the interval cancers among VDG4 were detected within the first year of the biennial screening interval. For VDG2, 26.3% were detected within the first year. The highest annual interval cancer rate (2.7 per 1000 examinations) was observed for VDG4 in the second year of the biennial interval. Annual screening of women with extremely dense breasts may reduce the interval cancer rate and increase program-wide sensitivity, especially in settings where supplemental MRI screening is not feasible.

Use of public sector diabetes eye services in New Zealand 2006-2019: Analysis of national routinely collected datasets.

To assess diabetes eye service use in New Zealand among people aged ≥15 years by estimating service attendance, biennial screening rate, and disparities in the use of screening and treatment services. We obtained Ministry of Health data from the National Non-Admitted Patient Collection on diabetes eye service events between 1 July 2006 and 31 December 2019 and sociodemographic and mortality data from the Virtual Diabetes Register and linked these using a unique patient identifier (encrypted National Health Index). We 1) summarized attendance at retinal screening and ophthalmology services, 2) calculated biennial and triennial screening rate, 3) summarized treatment with laser and anti-VEGF and used log-binomial regression to examine associations of all of these with age group, ethnicity, and area-level deprivation. In total, 245,844 people aged ≥15 years had at least one diabetes eye service appointment attended or scheduled; half of these (n = 125,821, 51.2%) attended only retinal screening, one-sixth attended only ophthalmology (n = 35,883, 14.6%) and one-third attended both (n = 78,300, 31.8%). The biennial retinal screening rate was 62.1%, with large regional variation (73.9% in Southern District to 29.2% in West Coast). Compared with NZ Europeans, Māori were approximately twice as likely to never receive diabetes eye care or to access ophthalmology when referred from retinal screening, 9% relatively less likely to receive biennial screening and received the fewest anti-VEGF injections when treatment was commenced. Disparities in service access were also present for Pacific Peoples compared to NZ Europeans, younger and older age groups compared to those aged 50-59 years and those living in areas with higher deprivation. Access to diabetes eye care is suboptimal, with substantial disparity between age groups, ethnicity groups, area level deprivation quintile and across districts. Efforts to improve access to and quality of diabetes eye care services must include strengthening data collection and monitoring.

Changes in metabolic syndrome and risk of breast and endometrial cancers according to menopause.

This study investigated how changes in metabolic syndrome (MetS) are associated with the subsequent risk of breast and endometrial cancer according to menopausal status. This cohort study, using data from the National Health Insurance Service database, included women aged ≥40 years who underwent 2 biennial cancer screenings (2009-2010 and 2011-2012) and were followed up until 2020. Participants were grouped into MetS-free, MetS-recovery, MetS-development, and MetS-persistent groups. Menopausal status (premenopausal, perimenopausal, and postmenopausal) was assessed at 2 screenings. Cox proportional hazard regression was used to assess the association between MetS changes and cancer risk. In 3,031,980 women, breast and endometrial cancers were detected in 39,184 and 4,298, respectively. Compared with the MetS-free group, those who recovered, developed, or had persistent MetS showed an increased risk of breast cancer, with adjusted hazard ratios (aHRs) of 1.05, 1.05, and 1.11, respectively (p<0.005). MetS persistence was associated with an increased risk of breast cancer in postmenopausal women (aHR=1.12, 95% CI, 1.08-1.16) but not in premenopausal or perimenopausal women. MetS persistence was associated with an increased risk of endometrial cancer in premenopausal, perimenopausal, and postmenopausal women, with aHRs of 1.41 (95% CI, 1.17-1.70), 1.59 (95% CI, 1.19-2.12), and 1.47 (95% CI, 1.32-1.63), respectively. Increased breast cancer risk was associated with recovered, developed, and persistent MetS in postmenopausal women. Meanwhile, increased endometrial cancer risk was found in obese women who recovered from MetS or persistently had MetS, regardless of menopausal status, when compared to MetS-free women.

Inverse association between changes in systolic and diastolic blood pressure and risk of depression: A nationally representative cohort study

BackgroundDepression is one of complex mental disorders with diverse etiological factors but the association between blood pressure (BP) and depression is unknown. We aimed to investigate the association between changes in BP (systolic and diastolic) and incident depression. MethodsFrom the National Health Insurance Service-Health Screening Cohort (NHIS-HEALS), 224,192 participants who underwent biennial health screenings from period I (2004–05) and II (2006–07) were included in the study. Systolic BP (SBP) and diastolic BP (DBP) categories were defined as follows: SBP into 5 categories (<90 mmHg, 90 mmHg −119 mmHg, 120 mmHg −129 mmHg, 130 mmHg −139 mmHg, ≥140 mmHg) and DBP into 4 categories (<60 mmHg, 60 mmHg −79 mmHg, 80 mmHg −89 mmHg, ≥90 mmHg). Also, BP levels were classified into 5 groups: normal, elevated BP, stage 1 BP, stage 2 BP, hypotension. Using the Cox proportional hazards regression, changes in SBP and DBP between two screening periods and the risk of depression were calculated by adjusted hazard ratio (aHR) and 95 % confidence interval (CI). ResultsThere were 17,780 depression events during 1.5 million person-year of follow-up. Compared to the participants with SBP ≥ 140 mmHg or DBP ≥ 90 mmHg from both periods, those who decreased SBP from ≥140 mmHg to 120 mmHg–129 mmHg (aHR 1.13; 95 % CI 1.04–1.24; P = 0.001) and those who decreased DBP from ≥90 mmHg to 60 mmHg–79 mmHg (aHR 1.10; 95 % CI 1.02–1.20; P = 0.020) showed a higher risk of depression, respectively. ConclusionsChanges in SBP and DBP showed an inverse relationship with depression risk.

Association of Physical Activity With SARS-CoV-2 Infection and Severe Clinical Outcomes Among Patients in South Korea

The association of moderate to vigorous physical activity (MVPA) with COVID-19 outcomes is unclear and needs to be investigated. To identify the association of longitudinal changes in MVPA with SARS-CoV-2 infection and severe COVID-19 outcomes. This nested case-control study used data from 6 396 500 adult patients in South Korean who participated in National Health Insurance Service (NHIS) biennial health screenings from period 1 (2017-2018) to period 2 (2019-2020). Patients were followed from October 8, 2020, until the diagnosis of COVID-19 or December 31, 2021. Moderate to vigorous physical activity was measured by self-report on questionnaires during both NHIS health screenings and calculated by adding the frequency (times per week) of each moderate (≥30 minutes per day) and vigorous (≥20 minutes per day) physical activity. The main outcomes were a positive diagnosis of SARS-CoV-2 infection and severe COVID-19 clinical events. Adjusted odds ratio (aORs) and 99% CIs were calculated using multivariable logistic regression analysis. A total of 183 350 patients with COVID-19 (mean [SD] age, 51.9 [13.8] years; female, 89 369 [48.7%]; male, 93 981 [51.3%]) among 2 110 268 participants were identified. For participants with vs without COVID-19, the proportion of MVPA frequency at period 2 was 35.8% vs 35.9% for physically inactive, 18.9% vs 18.9% for 1 to 2 times per week, 17.7% vs 17.7% for 3 to 4 times per week, and 27.5% vs 27.4% for 5 or more times per week. Among unvaccinated, physically inactive patients at period 1, the odds for infection increased when engaged in MVPA 1 to 2 times per week (aOR, 1.08; 99% CI, 1.01-1.15), 3 to 4 times per week (aOR, 1.09; 99% CI, 1.03-1.16), or 5 or more times per week (aOR, 1.10; 99% CI, 1.04-1.17) at period 2. Conversely, among unvaccinated patients with MVPA of 5 or more times per week at period 1, the odds for infection decreased when engaged 1 to 2 times per week (aOR, 0.90; 99% CI, 0.81-0.98) or physically inactive (aOR, 0.80; 99% CI, 0.73-0.87) at period 2. The trend of MVPA and incident infection was mitigated when participants were fully vaccinated. Furthermore, the odds for severe COVID-19 showed significant but limited associations with MVPA. The findings of this nested case-control study show a direct association of MVPA with risk of SARS-CoV-2 infection, which was mitigated after completion of the COVID-19 vaccination primary series. In addition, higher levels of MVPA were associated with a lower risk of severe COVID-19 outcomes to limited proportions.

Recalibration of a Deep Learning Model for Low-Dose Computed Tomographic Images to Inform Lung Cancer Screening Intervals

Annual low-dose computed tomographic (LDCT) screening reduces lung cancer mortality, but harms could be reduced and cost-effectiveness improved by reusing the LDCT image in conjunction with deep learning or statistical models to identify low-risk individuals for biennial screening. To identify low-risk individuals in the National Lung Screening Trial (NLST) and estimate, had they been assigned a biennial screening, how many lung cancers would have been delayed 1 year in diagnosis. This diagnostic study included participants with a presumed nonmalignant lung nodule in the NLST between January 1, 2002, and December 31, 2004, with follow-up completed on December 31, 2009. Data were analyzed for this study from September 11, 2019, to March 15, 2022. An externally validated deep learning algorithm that predicts malignancy in current lung nodules using LDCT images (Lung Cancer Prediction Convolutional Neural Network [LCP-CNN]; Optellum Ltd) was recalibrated to predict 1-year lung cancer detection by LDCT for presumed nonmalignant nodules. Individuals with presumed nonmalignant lung nodules were hypothetically assigned annual vs biennial screening based on the recalibrated LCP-CNN model, Lung Cancer Risk Assessment Tool (LCRAT + CT [a statistical model combining individual risk factors and LDCT image features]), and the American College of Radiology recommendations for lung nodules, version 1.1 (Lung-RADS). Primary outcomes included model prediction performance, the absolute risk of a 1-year delay in cancer diagnosis, and the proportion of people without lung cancer assigned a biennial screening interval vs the proportion of cancer diagnoses delayed. The study included 10 831 LDCT images from patients with presumed nonmalignant lung nodules (58.7% men; mean [SD] age, 61.9 [5.0] years), of whom 195 were diagnosed with lung cancer from the subsequent screen. The recalibrated LCP-CNN had substantially higher area under the curve (0.87) than LCRAT + CT (0.79) or Lung-RADS (0.69) to predict 1-year lung cancer risk (P < .001). If 66% of screens with nodules were assigned to biennial screening, the absolute risk of a 1-year delay in cancer diagnosis would have been lower for recalibrated LCP-CNN (0.28%) than LCRAT + CT (0.60%; P = .001) or Lung-RADS (0.97%; P < .001). To delay only 10% of cancer diagnoses at 1 year, more people would have been safely assigned biennial screening under LCP-CNN than LCRAT + CT (66.4% vs 40.3%; P < .001). In this diagnostic study evaluating models of lung cancer risk, a recalibrated deep learning algorithm was most predictive of 1-year lung cancer risk and had least risk of 1-year delay in cancer diagnosis among people assigned biennial screening. Deep learning algorithms could prioritize people for workup of suspicious nodules and decrease screening intensity for people with low-risk nodules, which may be vital for implementation in health care systems.

Abstract OT3-18-03: The PRAIM study: A prospective multicenter observational study of an integrated Artificial Intelligence system with live monitoring

Abstract Background. Several retrospective studies have illustrated the potential clinical benefit of artificial intelligence (AI) systems for breast cancer screening. Some systems optimize normal mammography examination triaging, while others aim to improve cancer detection. However, no AI system has shown specificity high enough to replace human radiologists, suggesting that AI should play a different role in the breast screening pathway. The decision-referral approach is a promising alternative that has demonstrated the most potential to improve radiologist screening sensitivity and specificity while reducing workload. This collaborative human-AI approach combines AI pre-screening to triage normal examinations and post-screening to prevent missed cancers. The actual performance of decision-referral, including the interaction with human radiologists, can ideally be evaluated in a prospective real-world setting. Trial design. The PRAIM (PRospective, multicenter observational study of an integrated AI system with live monitoring to support breast cancer screening) study (German Trial Register: DRKS00027322) is a prospective controlled observational non-inferiority study to compare the use of CE-marked screening software including AI support (Vara) via the decision-referral approach, with standard screening for women participating in the German breast cancer screening program. Ethics approval was obtained from the University of Lübeck Research Ethics Committee (22-043). Examinations assessed by readers using Vara are compared to examinations without Vara (control). Eligibility criteria and target accrual. Women ages 50 to 69 years old undergoing biennial breast cancer screening within the national screening program are eligible for inclusion. We expect the inclusion of approximately 400,000 women within the inclusion period of 1.5 years. Statistical methods. The primary outcome is the screen-detected cancer rate, defined as biopsy-confirmed cancer diagnoses per 1000 screening examinations. For each screening site, rates over the prospective observation period are calculated for examinations read with AI and without. To control for systematically different screen-detected cancer rates across screening sites, a historical 5-year rate is computed for each site and subtracted from the corresponding prospective rates. Non-inferiority of the screen-detected cancer rate for the AI group compared to the control group is evaluated with a weighted, mixed-effects linear regression model. AI is considered as non-inferior if the lower bound of the two-sided 95 % confidence interval for the estimated difference in screen-detected cancer rates of AI and non-AI group is not below -10 %, which corresponds to a deviation of -0.6 screen-detected cancers per 1000 examinations. Citation Format: Danalyn Byng, Nora Eisemann, Dominik Schüler, Stefan Bunk, Christian Leibig, Moritz Brehmer, Susanne Elsner, Alexander Katalinic. The PRAIM study: A prospective multicenter observational study of an integrated Artificial Intelligence system with live monitoring [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT3-18-03.

Cumulative 6-Year Risk of Screen-Detected Ductal Carcinoma In Situ by Screening Frequency

Detection of ductal carcinoma in situ (DCIS) by mammography screening is a controversial outcome with potential benefits and harms. The association of mammography screening interval and woman's risk factors with the likelihood of DCIS detection after multiple screening rounds is poorly understood. To develop a 6-year risk prediction model for screen-detected DCIS according to mammography screening interval and women's risk factors. This Breast Cancer Surveillance Consortium cohort study assessed women aged 40 to 74 years undergoing mammography screening (digital mammography or digital breast tomosynthesis) from January 1, 2005, to December 31, 2020, at breast imaging facilities within 6 geographically diverse registries of the consortium. Data were analyzed between February and June 2022. Screening interval (annual, biennial, or triennial), age, menopausal status, race and ethnicity, family history of breast cancer, benign breast biopsy history, breast density, body mass index, age at first birth, and false-positive mammography history. Screen-detected DCIS defined as a DCIS diagnosis within 12 months after a positive screening mammography result, with no concurrent invasive disease. A total of 916 931 women (median [IQR] age at baseline, 54 [46-62] years; 12% Asian, 9% Black, 5% Hispanic/Latina, 69% White, 2% other or multiple races, and 4% missing) met the eligibility criteria, with 3757 screen-detected DCIS diagnoses. Screening round-specific risk estimates from multivariable logistic regression were well calibrated (expected-observed ratio, 1.00; 95% CI, 0.97-1.03) with a cross-validated area under the receiver operating characteristic curve of 0.639 (95% CI, 0.630-0.648). Cumulative 6-year risk of screen-detected DCIS estimated from screening round-specific risk estimates, accounting for competing risks of death and invasive cancer, varied widely by all included risk factors. Cumulative 6-year screen-detected DCIS risk increased with age and shorter screening interval. Among women aged 40 to 49 years, the mean 6-year screen-detected DCIS risk was 0.30% (IQR, 0.21%-0.37%) for annual screening, 0.21% (IQR, 0.14%-0.26%) for biennial screening, and 0.17% (IQR, 0.12%-0.22%) for triennial screening. Among women aged 70 to 74 years, the mean cumulative risks were 0.58% (IQR, 0.41%-0.69%) after 6 annual screens, 0.40% (IQR, 0.28%-0.48%) for 3 biennial screens, and 0.33% (IQR, 0.23%-0.39%) after 2 triennial screens. In this cohort study, 6-year screen-detected DCIS risk was higher with annual screening compared with biennial or triennial screening intervals. Estimates from the prediction model, along with risk estimates of other screening benefits and harms, could help inform policy makers' discussions of screening strategies.

Overcoming barriers: Modelling the effect of potential future changes of organized breast cancer screening in Italy.

Organized breast cancer screening may not achieve its full potential due to organizational and cultural barriers. In Italy, two identified barriers were low attendance in Southern Italy and, in Italy as a whole, underscreening and overscreening in parts of the eligible population. The objective of this study was to identify potential changes to overcome these barriers and to quantify their costs and effects. To assess the impact of potential measures to improve breast cancer screening in Italy, we performed an evaluation of costs and effects for increasing adherence for Southern Italy and harmonizing screening intervals (biennial screening) for the whole of Italy, using an online tool (EU-TOPIA evaluation tool) based on the MIcrosimulation SCreening ANalysis (MISCAN) model. Increasing adherence in Southern Italy through investing in mobile screening units has an acceptable cost-effectiveness ratio of €9531 per quality-adjusted life year gained. Harmonizing the screening interval by investing in measures to reduce opportunistic screening and simultaneously investing in mobile screening units to reduce underscreening is predicted to gain 1% fewer life-years, while saving 19% of total screening costs compared to the current situation. Increasing adherence in Southern Italy and harmonizing the screening interval could result in substantial improvements at acceptable costs, or in the same benefits at lower costs. This example illustrates a systematic approach that can be easily applied to other European countries, as the online tools can be used by stakeholders to quantify effects and costs of a broad range of specific barriers, and ways to overcome them.

Digital Breast Tomosynthesis: A Decade of Practice in Review

Digital breast tomosynthesis (DBT), introduced in 2011, was thought to be a further evolution of full-field digital mammography (DM). Assessing DBT presents unique challenges. The widely variable settings in which DBT has been applied affect outcomes. In initial studies comparing DM-DBT with DM, outcomes for cancer detection rates (CDRs) and recall rates have been mixed. CDR improves most in biennial screening settings, with little or no improvement in annual screening. Recall rates improve most where rates are highest; no improvement is seen in European prospective trials. Adoption of synthesized mammography (SM), derived from the tomosynthesis acquisition and intended to avoid the DM exposure, has been slow because of inferior image quality. Despite this, SM-DBT has shown equivalent outcomes measures to DM-DBT. An important exception is the To-Be randomized controlled trial, which showed that SM-DBT was equivalent to DM in CDR, not better. To date, interval cancer rate, a surrogate for mortality reduction, has not been shown to be improved by DBT. We may have reached the limit of morphological assessment in x-ray technique. Its use may evolve with advancements in technology as use of contrast agents expands, algorithms for SM progress, and tomosynthesis-guided biopsy proliferates. Our expectations of the contributions of DBT will evolve as well.

Food security status and breast cancer screening among women in the United States: Evidence from the Health and Retirement Study and Health Care and Nutrition Study

To assess the impact of food insecurity on biennial breast cancer screenings (i.e., mammography or breast X-ray) among older women in the United States (US). Data from the 2014 and 2016 waves of the Health and Retirement Study and the 2013 Health Care and Nutrition Study were used. The analyses were limited to a nationally representative sample of 2,861 women between 50 and 74years of age, residing in the US. We employed a propensity score weighting method to balance observed confounders between food-secure and food-insecure women and fit a binary logistic regression to investigate population-level estimates for the association between food security and breast cancer screening. Food insecurity was significantly associated with failure to obtain a mammogram or breast X-ray within the past two years. Food-insecure women had 54% lower odds of reporting breast cancer screening in the past 2years (adjusted OR = 0.46; 95% CI 0.30-0.70, p-value < 0.001) as compared to food-secure women. Additional factors associated with a higher likelihood of receiving breast cancer screenings included greater educational attainment, higher household income, regular access to health care/advice, not smoking, and not being physically disabled or experiencing depressive symptoms. Results demonstrate a socioeconomic gradient existing in regard to the utilization of regular breast cancer screenings among women. Those who tend to have lower education, lower income, and lack of reliable healthcare access are more likely to be food insecure. Thus, more likely to face the financial, logistical, or environmental barriers in obtaining screening services that accompany food insecurity.

A Population-Based Helicobacter pylori Eradication Strategy Is More Cost-Effective than Endoscopic Screening

BackgroundHelicobacter pylori (HP) eradication therapy is an efficient primary prevention method to reduce gastric cancer development. In Japan, biennial endoscopic screening for individuals aged 50 years and older is currently conducted as a national gastric cancer prevention program.AimsWe aimed to evaluate which strategy was the most optimal and cost-effective among HP eradication strategy, annual, biennial, and triennial endoscopic screening, and no screening as a national gastric cancer prevention program.MethodsWe developed a state-transition model for HP eradication strategy, annual, biennial, and triennial endoscopic screening, and no screening using a healthcare payer perspective and a lifetime horizon. We targeted a hypothetical cohort of the Japanese population in their 20 s to 80 s. The main outcomes were costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, gastric cancer cases, and deaths from gastric cancer. We performed one-way, two-way, and probabilistic sensitivity analyses.ResultsHP eradication strategy was more cost-effective than endoscopic screening at any interval in all age groups. Cost-effectiveness was sensitive to HP infection rate. Cost-effective acceptability curves by Monte Carlo simulations for 10,000 trials demonstrated that HP eradication strategy was 100% cost-effective at a willingness-to-pay threshold of US$50,000 per QALY gained in all age groups. Over a lifetime, HP eradication strategy saves US$28.07 billion, increases 37.16 million QALYs, prevents 4.47 million gastric cancer cases, and saves 319,870 lives from gastric cancer.ConclusionA population-based HP eradication strategy is optimal and cost-effective for a national gastric cancer prevention program in Japan, replacing the current secondary prevention-focused biennial endoscopic screening.

Shall We Screen Lung Cancer With Low-Dose Computed Tomography? Cost-Effectiveness in Hungary

ObjectivesClinical data and cost-effectiveness analyses from several countries support the use of low-dose computed tomography (LDCT) to screen patients with high risk of lung cancer (LC). This study aimed to explore the economic value of screening LC with LDCT in Hungary. MethodsCohorts of screened and nonscreened subjects were simulated in a decision analytic model over their lifetime. Five steps in the patient trajectory were distinguished: no LC, nondiagnosed LC, screening, diagnosed LC, and post-treatment. Patient pathways were populated based on the Hungarian pilot study of screening, the Nederlands–Leuvens Longkanker Screenings Onderzoek (NELSON) LC screening trial, and local incidence and prevalence data. Healthcare costs were obtained from the National Health Insurance Fund. Utility data were obtained from international sources and adjusted to local tariffs. Scenarios according to screening frequency, age bands (50-74, 55-74 years), and smoking status were analyzed. ResultsAnnual LDCT-based screening compared with no screening for 55- to 74-year-old current smokers showed 0.031 quality-adjusted life-year (QALY) gains for an additional €137, which yields €5707 per QALY. Biennial screening for the same target population showed that purchasing 1 QALY would cost €10 203. The least cost-effective case was biennial screening of the general population aged 50 to 74 years, which yielded €37 931 per QALY. ConclusionsScreening LC with LDCT for a high-risk population could be cost-effective in Hungary. For the introduction of screening with LDCT, targeting the most vulnerable groups while having a long-term approach on costs and benefits is essential.

Trends in breast cancer screening rates among Korean women: results from the Korean National Cancer Screening Survey, 2005-2020.

Since 2002, the Korean government has provided breast cancer screening as part of the National Cancer Screening Program. This study reported trends in the screening rate among Korean women from 2005 to 2020, including organized and opportunistic screening for breast cancer. Data from the Korean National Cancer Screening Survey, an annual cross-sectional nationwide survey, were collected using a structured questionnaire between 2005 and 2020. The study population included 23,702 women aged 40-74 years with no history of cancer. We estimated the screening rate based on the current recommendation of biennial mammographic screening for breast cancer. In addition, a joinpoint trend analysis was performed for breast cancer screening rates among various subgroups. In 2020, the breast cancer screening rate was 63.5%, reflecting an annual increase of 7.72% (95% confidence interval 5.53 to 9.95) between 2005 and 2012, followed by non-significant trends thereafter. In particular, a significant decrease in the breast cancer screening rate was observed in the subgroups aged 50-59 years old, with 12-15 years of education, and living in rural areas. Although there has been substantial improvement in breast cancer screening rates in Korean women, the trend has flattened in recent years. Therefore, continual efforts are required to identify subgroups with unmet needs and solve barriers to the uptake of breast cancer screening.

Abstract 11425: Association of Glycemic Control With Cardiovascular Outcomes in Adult Cancer Survivors With Elevated Fasting Blood Glucose Level: A Population-Based Cohort Study

Introduction: Management of blood glucose level is recommended for prevention of cardiovascular disease (CVD) and other health outcomes by well-regarded guidelines. However, whether glycemic control is associated with incident CVD in adult cancer survivors with elevated fasting blood glucose (FBG) level remains unknown. Hypothesis: We hypothesized that adult cancer survivors with elevated FBG level (FBG≥100 mg/dL) whose FBG level was lowered to the normal range (FBG&lt;100 mg/dL) would be at lower risk of incident CVD compared to those whose FBG level was persistently elevated. Methods: Population-based cohort study derived from the National Health Insurance Service database identified adult cancer survivors between January 1, 2002 and December 31, 2005 who underwent the two consecutive biennial national health screening program (2007-2008 and 2009-2010) in the Republic of Korea. Follow-up data for incident CVD and death from CVD or other causes was obtained from the medical claims records and death registry, respectively. Each survivor was followed-up from January 1, 2011 to December 31, 2019 until incident CVD, death from CVD or other causes, whichever came first. The risk estimates for CVD outcomes were computed with Cox proportional hazards model adjusted for age, sex, insurance premium, lipid profile, hypertension, obesity, cigarette smoking, and physical activity among adult cancer survivors with and without glycemic control. Results: A total of 4,959 adult cancer survivors with elevated FBG level was identified in the NHIS database. Among these survivors, proportion of those whose FBG level was lowered to the normal range was 36.2% (n=1,785). After adjusting for sociodemographic, lifestyle, and clinical characteristics, adult cancer survivors with lowered FBG level compared to those who had persistently elevated FBG level were less likely to be at risk of incident CVD (adjusted hazard ratio=0.69; 95% confidence intervals: 0.24-1.98). Conclusions: No statistically significant risk estimate was observed in this analysis, which is likely to be underpowered. Well-designed observational studies are needed to examine the association of glycemic control with CVD events among adult cancer survivors with elevated FBG level.

Young Age on Starting Prostate-specific Antigen Testing Is Associated with a Greater Reduction in Prostate Cancer Mortality: 24-Year Follow-up of the Göteborg Randomized Population-based Prostate Cancer Screening Trial

BackgroundThe risk of death from prostate cancer (PC) depends on age, but the age at which to start prostate-specific antigen (PSA) screening remains uncertain. ObjectiveTo study the relationship between risk reduction for PC mortality and age at first PSA screening. Design, setting, and participantsThe randomized Göteborg-1 trial invited men for biennial PSA screening between the ages of 50 and 70 yr (screening, n = 10 000) or no invitation but exposure to opportunistic PSA testing (control, n = 10 000). InterventionRegular versus opportunistic PSA screening or no PSA. Outcome measurements and statistical analysisWe modeled the nonlinear association between starting age and the absolute risk reduction in PC mortality in three settings: (1) intention-to-screen (randomized arms); (2) historical control (screening group and 1990–1994 registry data); and (3) attendees only (screening attendees and matched controls). We tested whether the effect of screening on PC mortality depends on the age at starting screening by comparing survival models with and without an interaction between trial arm and age (intention-to-screen and attendees only). Results and limitationsYounger age on starting PSA testing was associated with a greater reduction in PC mortality. Starting screening at age 55 yr approximately halved the risk of PC death compared to first PSA at age 60 yr. The test of association between starting age and the effect of screening on PC mortality was slightly greater than the conventional level of statistical significance (p = 0.052) for the entire cohort, and statistically significant among attendees (p = 0.002). This study is limited by the low number of disease-specific deaths for men starting screening before age 55 yr and the difficulty in discriminating between the effect of starting age and screening duration. ConclusionsGiven that prior screening trials included men aged up to 70 yr on starting screening, our results suggest that the effect size reported in prior trials underestimates that of currently recommended programs starting at age 50–55 yr. Patient summaryIn this study from the Göteborg-1 trial, we looked at the effect of prostate-specific antigen (PSA) screening in reducing men’s risk of dying from prostate cancer given the age at which they begin testing. Starting at a younger age reduced the risk of prostate cancer death by a greater amount. We recommend that PSA screening should start no later than at age 55 yr.

103 (PB-103) Poster - Interhospital variations in diagnostic work-up following recall at biennial screening mammography – a population-based study

Background and aim: Quality control in breast cancer screening itself has been subject of previous studies. Less is known about the work-up after recall, in particular possible interhospital variations regarding work-up. Knowledge about possible differences might aid in further optimizing breast cancer care and is therefore subject of the current study. Methods: In this retrospective analysis using a prospectively obtained database, we included 17.809 women who experienced a recall in the Dutch national screening program between 2009 and 2019. The diagnostic work-up (e.g. type of additional imaging, frequency and type of biopsy) in seven hospital groups was compared and analyzed using a multivariable logistic regression. Results: After correction for patient and tumor characteristics, significant differences were found in the diagnostic work-up between the seven hospital groups. Both the number of biopsies and the percentage of problem-solving MRI’s performed were significantly different (smallest OR 0.53 95% CI 0.42– 0.66, and smallest OR 0.30; 95% CI 0.18–0.51, respectively). No significant difference was found regarding type of biopsy (percutaneous vs. excision) after adjustment for cofounders (smallest OR 0.38 95% CI 0.15–0.97). Conclusion: The seven hospital groups in our screening region show a significant difference in number of biopsies and percentage of problem-solving MRI’s performed in women recalled at biennial screening mammography. A consistency in work-up between different hospitals might further improve the standard of care for screened women. However, additional research on the effects of these differences is needed to make any definite recommendations. No conflict of interest.

Multilevel Small Area Estimation for County-Level Prevalence of Mammography Use in the United States Using 2018 Data.

Background: The U.S. Preventive Services Task Force recommends biennial screening mammography for average-risk women aged 50-74 years. We aim to generate county-level prevalence estimates for mammography use to examine disparities among counties. Materials and Methods: We used data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 111,902 women) and linked them to county-level data from the American Community Survey. We defined two outcomes: mammography within the past 2 years (current); and mammography 5 or more years ago or never (rarely or never). We poststratified the data with U.S. Census estimated county population counts, ran Monte Carlo simulations, and generated county-level estimates. We aggregated estimates to state and national levels. We validated internal consistency between our model-based and BRFSS state estimates using Spearman and Pearson correlation coefficients. Results: Nationally, more than three in four women [78.7% (95% confidence interval {CI}: 78.2%-79.2%)] were current with mammography, although with large variations among counties. Also, nationally, about one in nine women [11% (95% CI: 10.8%-11.3%)] rarely or never had a mammogram. County estimates for being current ranged from 60.4% in New Mexico to 86.9% in Hawaii. Rarely or never having a mammogram ranged from 6% in Connecticut to 23.0% in Alaska, and on average, almost one in eight women in all the counties. Internal consistency correlation coefficient tests were ≥0.94. Conclusions: Our analyses identified marked county variations in mammography use across the country among women aged 50-74 years. We generated estimates for all counties, which may be helpful for targeted outreach to increase mammography uptake.