Comparative Effectiveness of Combined Digital Mammography and Tomosynthesis Screening for Women with Dense Breasts

Abstract

Purpose To evaluate the comparative effectiveness of combined biennial digital mammography and tomosynthesis screening, compared to biennial digital mammography screening alone, among women with dense breasts. Materials and Methods We used an established, discrete-event breast cancer simulation model to estimate the comparative clinical effectiveness and cost-effectiveness of biennial screening with both digital mammography and tomosynthesis versus digital mammography alone among U.S. women ages 50–74 years with dense breasts from a federal payer perspective and a lifetime horizon. We estimated input values for test performance, costs, and health state utilities from the National Cancer Institute’s Breast Cancer Surveillance Consortium, Medicare reimbursement rates, and the medical literature. We performed sensitivity analyses to determine the implications of varying key model parameters, including combined screening sensitivity and specificity, transient utility decrement of diagnostic work-up, and the additional cost of tomosynthesis. Results For our base case analysis, the incremental cost per quality-adjusted life year (QALY) gained by adding tomosynthesis to digital mammography screening was $53,893. An additional 0.5 deaths were averted and 405 false-positives were avoided per 1,000 women after 12 rounds of screening. Combined screening remained cost-effective (less than $100,000 per QALY gained) over a wide range of incremental improvements in test performance. Overall, cost-effectiveness was most sensitive to the additional cost of tomosynthesis. Conclusion Biennial combined digital mammography and tomosynthesis screening for U.S. women aged 50–74 years with dense breasts is likely to be cost-effective if priced appropriately (≤ $226 combined exams versus $139 for digital mammography alone) and if reported interpretive performance metrics of improved specificity with tomosynthesis are met in routine practice.

Cost-Effectiveness of Breast Cancer Screening in Turkey, a Developing Country: Results from Bahçeşehir Mammography Screening Project

“…Therefore, this assumption may have caused our study to underestimate the benefits of screening. Ideally, one would use an established microsimulation model such as those used as part of NCI's Cancer Intervention Surveillance Network (CISNET) project to estimate the life expectancies for women undergoing screening more accurately (38)(39)(40). However, there is no such validated model that uses primary data of Turkish female population; therefore, we leave this for future research.…”

Imaging Management of Breast Density, a Controversial Risk Factor for Breast Cancer

“…In a study by Lee et al, 26 simulation models of breast cancer were utilized. Compared with biennial FFDM alone, the researchers showed that combined biennial FFDM and digital breast tomosynthesis for US women aged 50 to 74 years with dense breasts would avert 1 additional breast cancerrelated death per 2,000 women screened as well as 405 false-positive findings on screening examinations per 1,000 women.…”

“…Compared with biennial FFDM alone, the researchers showed that combined biennial FFDM and digital breast tomosynthesis for US women aged 50 to 74 years with dense breasts would avert 1 additional breast cancerrelated death per 2,000 women screened as well as 405 false-positive findings on screening examinations per 1,000 women. 26 They concluded that adding tomosynthesis to biennial FFDM for women aged 50 to 74 years with dense breasts was likely to improve health outcomes at a reasonable cost. 26 Thus, the evidence supports the finding that digital breast tomosynthesis improves detection rates of breast cancer with both increased sensitivity and specificity.…”

“…26 They concluded that adding tomosynthesis to biennial FFDM for women aged 50 to 74 years with dense breasts was likely to improve health outcomes at a reasonable cost. 26 Thus, the evidence supports the finding that digital breast tomosynthesis improves detection rates of breast cancer with both increased sensitivity and specificity. However, its potential drawbacks include increased interpretation time and higher doses of radiation.…”

Beyond the Mammography Debate: A Moderate Perspective

“…In the interim, the three-dimensional reconstruction technology of digital breast tomosynthesis was approved by Health Canada (in 2009, but is limited in availability) and by the U.S. Food and Drug Administration [but only as an adjunct to two-dimensional (2D) mammographic imaging] [117][118][119][120] . One appeal is the reduction of false-positives (approximately 15%) and increased cancer detection rates (approximately 28%; for invasive cancers, 40% or more) [121][122][123] , together with a onethird reduction in recall rates and consequent false-positive biopsies 117,124,125 , especially in younger women and women with dense breasts in whom mammography is limited, and with no negative effect on sensitivity 123,[126][127][128] , which could potentially tip the risk:benefit ratio toward tomosynthesis 129,130 .…”