Is risk-stratified breast cancer screening economically efficient in Germany?

Abstract

Objectives Risk stratification has so far been evaluated under the assumption that women fully adhere to screening recommendations. However, the participation in German cancer screening programs remains low at 54%. The question arises whether risk-stratified screening is economically efficient under the assumption that adherence is not perfect. Method We have adapted a micro-simulation Markov model to the German context. Annual, biennial, and triennial routine screening are compared with five risk-adapted strategies using thresholds of relative risk to stratify screening frequencies. We used three outcome variables (mortality reduction, quality-adjusted life years, and false-positive results) under the assumption of full adherence vs. an adherence rate of 54%. Strategies are evaluated using efficiency frontiers and probabilistic sensitivity analysis (PSA). Results The reduced adherence rate affects both performance and cost; incremental cost-effectiveness ratios remain constant. The results of PSA show that risk-stratified screening strategies are more efficient than biennial routine screening under certain conditions. At any willingness-to-pay (WTP), there is a risk-stratified alternative with a higher likelihood of being the best choice. However, without explicit decision criteria and WTP, risk-stratified screening is not more efficient than biennial routine screening. Potential improvements in the adherence rates have significant health gains and budgetary implications. Conclusion If the participation rate for mammographic screening is as low as in Germany, stratified screening is not clearly more efficient than routine screening but dependent on the WTP. A more promising design for future stratified strategies is the combination of risk stratification mechanisms with interventions to improve the low adherence in selected high-risk groups.

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

“…All studies, except for Arnold et al, 31 reported significant QALY/LYG for RBS strategies. Among the articles 32,33,36 that incorporated risk‐stratification cost, Gray et al 33 and Sun et al 36 reported no cost‐savings.…”

“…All studies are either from upper‐middle‐income (China and Spain) or high‐income countries (World Bank classification). Most of the studies adopted the payer perspective (government taxation and/or health insurance financing) 13,17,18,21,31‐34 . The societal perspective, which in addition to direct medical costs, also considers the cost of care that do not fall on the payer's perspective (OOPs, caregiver effects and patient time) and the indirect costs (productivity losses related to morbidity and mortality) are broadly neglected.…”

“…Similarly, two studies 21,35 stratified women based only on the individual's breast density and age. Four studies 13,17,18,31 estimated relative risk using a combination of breast density, family history and other risk factors. Pashayan et al 32 used genetic susceptibility loci and epidemiological risk factors, and Sankatsing et al 34 did not report the included risk factors.…”

“…A higher number of risk factors were incorporated in the recent studies, 18,32,33,36 such as Jewish ancestry, reproductive and lifestyle factors, genetic susceptibility loci and exposure to ionising radiations. The risk group categories varied among the studies: two risk groups (high‐risk and low‐risk), 21,32,34‐36 three risk groups (high‐risk, medium‐risk and low‐risk), 31,33 four risk groups (low‐risk, medium‐low‐risk, medium‐high‐risk and high‐risk), 17 and 16 population subgroups 18 . One study did not categorise the study population in risk clusters 13 …”

Cost-effectiveness of guideline-based stepped and collaborative care versus treatment as usual for patients with depression – a cluster-randomized trial

“…Despite potential cultural differences in preferences for health states between the German and the British population, we believe that the British value set is more useful to value health states in our sample. Additionally, we want to point out that using the British value set in a non-UK-based study is a frequently implemented approach [46][47][48][49].…”