Cost‐effectiveness of risk‐based breast cancer screening: A systematic review

Abstract

To analyse published evidence on the economic evaluation of risk‐based screening (RBS), a full systematic literature review was conducted. After a quality appraisal, we compared the cost‐effectiveness of risk‐based strategies (low‐risk, medium‐risk and high‐risk) with no screening and age‐based screening. Studies were also analysed for modelling, risk stratification methods, input parameters, data sources and harms and benefits. The 10 modelling papers analysed were based on screening performance of film‐based mammography (FBM) (three); digital mammography (DM) and FBM (two); DM alone (three); DM, ultrasound (US) and magnetic resonance imaging (one) and DM and US (one). Seven studies did not include the cost of risk‐stratification, and one did not consider the cost of diagnosis. Disutility was incorporated in only six studies (one for screening and five for diagnosis). None of the studies reported disutility of risk‐stratification (being considered as high‐risk). Risk‐stratification methods varied from only breast density (BD) to the combination of familial risk, genetic susceptibility, lifestyle, previous biopsies, Jewish ancestry and reproductive history. Less or no screening in low‐risk women and more frequent mammography screening in high‐risk women was more cost‐effective compared to no screening and age‐based screening. High‐risk women screened annually yielded a higher mortality rate reduction and more quality‐adjusted life years at the expense of higher cost and false positives. RBS can be cost effective compared to the alternatives. However, heterogeneity among risk‐stratification methods, input parameters, and weaknesses in the methodologies hinder the derivation of robust conclusions. Therefore, further studies are warranted to assess newer technologies and innovative risk‐stratification methods.

Views of health professionals on risk-based breast cancer screening and its implementation in the Spanish National Health System: A qualitative discussion group study

“…In addition, our study participants assume that there is an increase in costs derived from the genetic information in risk measurement and the time spent by professionals in communicating risk and shared decision-making. These costs would be largely offset by the increased effectiveness and efficiency of risk-based screening [3,9,[50][51][52][53], as well as by greater well-being provided by fluid communication between women and professionals regarding risk monitoring [18,54]. A reduction of professionals' workloads could be achieved if women participated more actively (e.g.…”

“…Our study participants argued that the costs of updating the IT system and implementing shared decision-making, together with the aforementioned costs of genetic determinations and human resources for risk communication, will lead to budget increases. However, there is evidence in favor of risk-based screening being more efficient [3,[51][52][53], providing more resources to women at higher risk and fewer to those at lower risk. Harkness et al [52] showed that compared to age-based screening, not offering screening to women in the lowest tertile of risk could improve effectiveness, cost-effectiveness, and decrease overdiagnosis, whilst resulting in a small excess of breast cancer deaths.…”

Barriers and Facilitators to the Implementation of a Personalized Breast Cancer Screening Program: Views of Spanish Health Professionals

“…Khan et al [7] conducted a systematic review that included 10 modeling studies and concluded that risk-based breast cancer screening is cost-effective compared to age-based screening. However, the authors warned of potential biases due to the non-integration of cost and utility parameters for all phases of screening and diagnosis and claimed that more evidence is needed on risk calculation, risk thresholds, screening outcomes by risk categories, and cost and utility parameters.…”

Management of Non-Mass Enhancement at Breast Magnetic Resonance in Screening Settings Referred for Magnetic Resonance-Guided Biopsy

“… 13 However, few studies reported the MRI harms and how we can manage and reduce the false-positive results. 14 - 16 According to the Breast Imaging and Reporting Data System (BI-RADS) fifth edition lexicon, one of the main limitations of MRI lies in diagnosing the NME. 17 The NME lesion is challenging since it is unique for the MRI lexicon, and its management and follow-up lack standardization.…”