Cost-effectiveness of different reading and referral strategies in mammography screening in the Netherlands

Groenewoud, Johanna H.; Otten, J.D.M.; Fracheboud, Jacques; Draisma, Gerrit; Holland, Roland; Verbeek, A.L.M.; Koning, Harry J. de

doi:10.1007/s10549-006-9319-4

Cited by 23 publications

(18 citation statements)

References 20 publications

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“…As reported previously, the highest CDR and sensitivity would have been obtained by quadruple reading by two radiologists and two radiographers, followed by referral of all radiologist and/or radiographer-positive readings (Duijm et al, 2007). The 2.04% referral rate at this reading strategy would still be cost effective in the Dutch screening programme (Otten et al, 2005;Groenewoud et al, 2007). There is a delicate balance between referral rate and cancer detection rate (Yankaskas et al, 2001).…”

Section: Discussionmentioning

confidence: 62%

Inter-observer variability in mammography screening and effect of type and number of readers on screening outcome

et al. 2009

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We prospectively determined the variability in radiologists' interpretation of screening mammograms and assessed the influence of type and number of readers on screening outcome. Twenty-one screening mammography radiographers and eight screening radiologists participated. A total of 106 093 screening mammograms were double-read by two radiographers and, in turn, by two radiologists. Initially, radiologists were blinded to the referral opinion of the radiographers. A woman was referred if she was considered positive at radiologist double-reading with consensus interpretation or referred after radiologist review of positive cases at radiographer double-reading. During 2-year follow-up, clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all women with a positive screening result from any reader. Single radiologist reading (I) resulted in a mean cancer detection rate of 4.64 per 1000 screens (95% confidence intervals (CI) ¼ 4.23 -5.05) with individual variations from 3.44 (95% CI ¼ 2.30 -4.58) to 5.04 (95% CI ¼ 3.81 -6.27), and a sensitivity of 63.9% (95% CI ¼ 60.5 -67.3), ranging from 51.5% (95% CI ¼ 39.6 -63.3) to 75.0% (95% CI ¼ 65.3 -84.7). Sensitivity at non-blinded, radiologist double-reading (II), radiologist double-reading followed by radiologist review of positive cases at radiographer double-reading (III), triple reading by one radiologist and two radiographers with referral of all positive readings (IV) and quadruple reading by two radiologists and two radiographers with referral of all positive readings (V) were as follows: 68.6% (95% CI ¼ 65.3 -71.9) (II); 73.2% (95% CI ¼ 70.1 -76.4) (III); 75.2% (95% CI ¼ 72.1 -78.2) (IV), and 76.9% (95% CI ¼ 73.9 -79.9) (V). We conclude that screener performance significantly varied at singlereading. Double-reading increased sensitivity by a relative 7.3%. When there is a shortage of screening radiologists, triple reading by one radiologist and two radiographers may replace radiologist double-reading.

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Section: Discussionmentioning

confidence: 62%

Inter-observer variability in mammography screening and effect of type and number of readers on screening outcome

et al. 2009

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“…The analyses were based in a number of countries including the USA (n = 18 239,257,263,267,271,272,274,275,277,278,283,[289][290][291][292][293]295,298 ), the UK (n = 15 241,243,246,247,249,253,261,265,273,276,279,287,297,299,303 ), the Netherlands (n = 4 242,244,256,259 ), Hong Kong (n = 4 [304][305][306][307] ), Australia (n = 3 254,262,302 ), Italy (n = 3 245,251,252 ), Japan (n = 2 284,…”

Section: Study Overviewmentioning

confidence: 99%

Improvement in risk prediction, early detection and prevention of breast cancer in the NHS Breast Screening Programme and family history clinics: a dual cohort study

Evans

Astley

Stavrinos³

et al. 2016

Programme Grants Appl Res

117

126

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BackgroundIn the UK, women are invited for 3-yearly mammography screening, through the NHS Breast Screening Programme (NHSBSP), from the ages of 47–50 years to the ages of 69–73 years. Women with family histories of breast cancer can, from the age of 40 years, obtain enhanced surveillance and, in exceptionally high-risk cases, magnetic resonance imaging. However, no NHSBSP risk assessment is undertaken. Risk prediction models are able to categorise women by risk using known risk factors, although accurate individual risk prediction remains elusive. The identification of mammographic breast density (MD) and common genetic risk variants [single nucleotide polymorphisms (SNPs)] has presaged the improved precision of risk models.ObjectivesTo (1) identify the best performing model to assess breast cancer risk in family history clinic (FHC) and population settings; (2) use information from MD/SNPs to improve risk prediction; (3) assess the acceptability and feasibility of offering risk assessment in the NHSBSP; and (4) identify the incremental costs and benefits of risk stratified screening in a preliminary cost-effectiveness analysis.DesignTwo cohort studies assessing breast cancer incidence.SettingHigh-risk FHC and the NHSBSP Greater Manchester, UK.ParticipantsA total of 10,000 women aged 20–79 years [Family History Risk Study (FH-Risk); UK Clinical Research Network identification number (UKCRN-ID) 8611] and 53,000 women from the NHSBSP [aged 46–73 years; Predicting the Risk of Cancer At Screening (PROCAS) study; UKCRN-ID 8080].InterventionsQuestionnaires collected standard risk information, and mammograms were assessed for breast density by a number of techniques. All FH-Risk and 10,000 PROCAS participants participated in deoxyribonucleic acid (DNA) studies. The risk prediction models Manual method, Tyrer–Cuzick (TC), BOADICEA (Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm) and Gail were used to assess risk, with modelling based on MD and SNPs. A preliminary model-based cost-effectiveness analysis of risk stratified screening was conducted.Main outcome measuresBreast cancer incidence.Data sourcesThe NHSBSP; cancer registration.ResultsA total of 446 women developed incident breast cancers in FH-Risk in 97,958 years of follow-up. All risk models accurately stratified women into risk categories. TC had better risk precision than Gail, and BOADICEA accurately predicted risk in the 6268 single probands. The Manual model was also accurate in the whole cohort. In PROCAS, TC had better risk precision than Gail [area under the curve (AUC) 0.58 vs. 0.54], identifying 547 prospective breast cancers. The addition of SNPs in the FH-Risk case–control study improved risk precision but was not useful inBRCA1(breast cancer 1 gene) families. Risk modelling of SNPs in PROCAS showed an incremental improvement from using SNP18 used in PROCAS to SNP67. MD measured by visual assessment score provided better risk stratification than automatic measures, despite wide intra- and inter-reader variability. Using a MD-adjusted TC model in PROCAS improved risk stratification (AUC = 0.6) and identified significantly higher rates (4.7 per 10,000 vs. 1.3 per 10,000;p < 0.001) of high-stage cancers in women with above-average breast cancer risks. It is not possible to provide estimates of the incremental costs and benefits of risk stratified screening because of lack of data inputs for key parameters in the model-based cost-effectiveness analysis.ConclusionsRisk precision can be improved by using DNA and MD, and can potentially be used to stratify NHSBSP screening. It may also identify those at greater risk of high-stage cancers for enhanced screening. The cost-effectiveness of risk stratified screening is currently associated with extensive uncertainty. Additional research is needed to identify data needed for key inputs into model-based cost-effectiveness analyses to identify the impact on health-care resource use and patient benefits.Future workA pilot of real-time NHSBSP risk prediction to identify women for chemoprevention and enhanced screening is required.FundingThe National Institute for Health Research Programme Grants for Applied Research programme. The DNA saliva collection for SNP analysis for PROCAS was funded by the Genesis Breast Cancer Prevention Appeal.

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“…21,23 MISCAN simulates individual life histories of women and the natural history of breast cancer in a subset of these women. First, breast cancer incidence and breast cancer mortality are estimated in a situation without screening.…”

Section: Model Overviewmentioning

confidence: 99%

Cost‐effectiveness of digital mammography screening before the age of 50 in The Netherlands

Sankatsing

Heijnsdijk

Luijt

et al. 2015

Intl Journal of Cancer

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In the Netherlands, routine mammography screening starts at age 50. This starting age may have to be reconsidered because of the increasing breast cancer incidence among women aged 40 to 49 and the recent implementation of digital mammography. We assessed the cost-effectiveness of digital mammography screening that starts between age 40 and 49, using a microsimulation model. Women were screened before age 50, in addition to the current programme (biennial 50-74). Screening strategies varied in starting age (between 40 and 50) and frequency (annual or biennial). The numbers of breast cancers diagnosed, life-years gained (LYG) and breast cancer deaths averted were predicted and incremental cost-effectiveness ratios (ICERs) were calculated to compare screening scenarios. Biennial screening from age 50 to 74 (current strategy) was estimated to gain 157 life years per 1,000 women with lifelong follow-up, compared to a situation without screening, and cost e3,376/ LYG (3.5% discounted). Additional screening increased the number of LYG, compared to no screening, ranging from 168 to 242. The costs to generate one additional LYG (i.e., ICER), comparing a screening strategy to the less intensive alternative, were estimated at e5,329 (biennial 48-74 vs. current strategy), e7,628 (biennial 45-74 vs. biennial 48-74), e10,826 (biennial 40-74 vs. biennial 45-74) and e18,759 (annual 40-49 1 biennial 50-74 vs. biennial 40-74). Other strategies (49 1 biennial 50-74 and annual 45-49 1 biennial 50-74) resulted in less favourable ICERs. These findings show that extending the Dutch screening programme by screening between age 40 and 49 is cost-effective, particularly for biennial strategies.Breast cancer is the most commonly diagnosed form of cancer among women aged 30 and older in the Netherlands. 1 Mammography screening allows for early detection and early treatment of breast cancer, with the aim of averting breast cancer death. In the Netherlands, women aged 50 to 74 are invited biennially to screening. Various randomised controlled trials demonstrated a statistically significant breast cancer mortality reduction due to mammography screening in this age group. 2-4 Furthermore, Otto et al. 5,6 showed that the Dutch population-based screening programme is effective in reducing breast cancer mortality. The evidence for the benefit of mammography screening for younger women is less conclusive, 7-9 however, an effect for this age group is supported by several studies. Although the UK Age Trial showed a non-significant 17% reduction in breast cancer mortality, 9 a statistically significant breast cancer mortality reduction of 15% to 18% associated with screening for women aged 39 to 49 or 40 to 49 at entry was demonstrated by several meta-analyses of randomised controlled trials. [10][11][12][13] In addition, a recent Swedish observational study that compared breast cancer mortality rates between women aged 40 and 49 who were invited to screening and women who were not invited to screening demonstrated a 26% statistically significant br...

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Cost-effectiveness of different reading and referral strategies in mammography screening in the Netherlands

Cited by 23 publications

References 20 publications

Inter-observer variability in mammography screening and effect of type and number of readers on screening outcome

Inter-observer variability in mammography screening and effect of type and number of readers on screening outcome

Improvement in risk prediction, early detection and prevention of breast cancer in the NHS Breast Screening Programme and family history clinics: a dual cohort study

Cost‐effectiveness of digital mammography screening before the age of 50 in The Netherlands

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