Cost of services provided by the National Breast and Cervical Cancer Early Detection Program

Can we increase efficiency of CT lung cancer screening by combining with CVD and COPD screening? Results of an early economic evaluation

Objectives

Estimating the maximum acceptable cost (MAC) per screened individual for low-dose computed tomography (LDCT) lung cancer (LC) screening, and determining the effect of additionally screening for chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), or both on the MAC.

Methods

A model-based early health technology assessment (HTA) was conducted to estimate whether a new intervention could be cost-effective by calculating the MAC at a willingness-to-pay (WTP) of €20k/quality-adjusted life-year (QALY) and €80k/QALY, for a population of current and former smokers, aged 50–75 years in The Netherlands. The MAC was estimated based on incremental QALYs gained from a stage shift assuming screened individuals are detected in earlier disease stages. Data were obtained from literature and publicly available statistics and validated with experts.

Results

The MAC per individual for implementing LC screening at a WTP of €20k/QALY was €113. If COPD, CVD, or both were included in screening, the MAC increased to €230, €895, or €971 respectively. Scenario analyses assessed whether screening-specific disease high-risk populations would improve cost-effectiveness, showing that high-risk CVD populations were more likely to improve economic viability compared to COPD.

Conclusions

The economic viability of combined screening is substantially larger than for LC screening alone, primarily due to benefits from CVD screening, and is dependent on the target screening population, which is key to optimise the screening program. The total cost of breast and cervical cancer screening is lower (€420) than the MAC of Big-3, indicating that Big-3 screening may be acceptable from a health economic perspective.

Key Points

• Once-off combined low-dose CT screening for lung cancer, COPD, and CVD in individuals aged 50–75 years is potentially cost-effective if screening would cost less than €971 per screened individual.

• Multi-disease screening requires detailed insight into the co-occurrence of these diseases to identify the optimal target screening population.

• With the same target screening population and WTP, lung cancer-only screening should cost less than €113 per screened individual to be cost-effective.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08422-7.

Contrast-Enhanced Digital Mammography: Technique, Clinical Applications, and Pitfalls

OBJECTIVE. Contrast-enhanced digital mammography (CEDM) combines the high spatial resolution of mammography with the improved enhancement provided by contrast medium. In this article, CEDM technique-the current and potential clinical applications and current challenges-will be reviewed. CONCLUSION. CEDM is a promising technique in the supplemental evaluation of patients with mammographically inconclusive findings and potentially in the screening of women with mammographically dense breasts. CEDM is emerging as a cost-effective alternative to dynamic contrast-enhanced MRI to stage newly diagnosed breast cancer and evaluate response to neoadjuvant chemotherapy.

Preventing Breast, Cervical, and Colorectal Cancer Deaths: Assessing the Impact of Increased Screening

Introduction

The US Preventive Services Task Force (USPSTF) recommends select preventive clinical services, including cancer screening. However, screening for cancers remains underutilized in the United States. The Centers for Disease Control and Prevention leads initiatives to increase breast, cervical, and colorectal cancer (CRC) screening. We assessed the number of avoidable deaths from increased screening, according to USPSTF recommendations, for CRC and female breast and cervical cancers.

Methods

We used model-based estimates of avoidable deaths for the lifetime of single-year age cohorts under the current and increased use of screening scenarios (data year 2016; analysis, 2018). We calculated prevented cancer deaths for each 1% increase in screening uptake and extrapolated to current level of screening (2016), current level plus 10 percentage points, and increasing screening to 90% and 100% of the eligible population.

Results

Increased use of screening from current levels to 100% would prevent an additional 2,821 deaths from breast cancer, 6,834 deaths from cervical cancer, and 35,530 deaths from CRC over a lifetime of the respective single-year cohort. Increasing use of CRC screening would prevent approximately 8.5 times as many deaths as the equivalent increase in use of breast cancer screening (women only), although twice as many people (men and women) would have to be screened for CRC.

Conclusions

A large number of deaths could be avoided by increasing breast, cervical, and CRC screening. Public health programs incorporating strategies shown to be effective can help increase screening rates.

An integrative literature review of barriers and facilitators to cervical cancer screening among refugee women in the United States

Refugee women experience disproportionally high cervical cancer-related mortality. In this integrative review, we identify and discuss factors related to cervical cancer screening among refugee women in the US according to the Social Ecological Model. Two qualitative and three quantitative studies met inclusion criteria. Individual-level factors include English-language ability, availability, and individual knowledge, attitudes, and beliefs. Interpersonal-level factors include interactions with family/friends, provider, and community health worker. Community-, organization-, and policy-level factors include sociocultural values, transportation, ability to navigate the healthcare system, and health insurance. We discuss findings in the context of related reviews and applicability to other global settings.

Economics of public health programs for underserved populations: a review of economic analysis of the National Breast and Cervical Cancer Early Detection Program

PURPOSE

The purpose of this paper is to provide a brief overview of economic analysis methods used in estimating the costs and benefits of public health programs and systematically review the application of these methods to the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

METHODS

Published literature on economic analyses of the NBCCEDP was systematically reviewed. The Consensus on Health Economic Criteria checklist was used to assess methodological quality of the included studies.

RESULTS

Methods available for economic analysis of public health programs include program cost, cost-effectiveness, cost-utility, cost-benefit analysis, and budget impact analysis. Of these, program cost analysis, cost-effectiveness analysis, and cost-utility analysis have been applied to the NBCCEDP in previously published literature.

CONCLUSION

While there have been multiple program cost analyses, there are relatively fewer cost-effectiveness and cost-utility studies and no cost-benefit and budget impact analysis studies to evaluate the NBCCEDP. Addressing these gaps will inform implementation of effective public health programs with equitable resource allocation to all population subgroups.

Updated medical care cost estimates for HPV-associated cancers: implications for cost-effectiveness analyses of HPV vaccination in the United States

Estimates of medical care costs for cervical and other cancers associated with human papillomavirus (HPV) are higher in studies published in recent years than in studies published before 2012. The purpose of this report is (1) to review and summarize the recent cancer cost estimates and (2) to illustrate how the estimated cost-effectiveness of HPV vaccination might change when these recent cost estimates are applied. Our literature search yielded 6 studies that provided updated medical care cost estimates for 5 HPV-associated cancers. We found that applying the current cancer cost estimates had a notable impact on the estimated medical costs averted by HPV vaccination over an extended time frame (100 years), and a moderate impact on the estimated cost per quality-adjusted life year (QALY) gained by HPV vaccination. For example, for catch-up vaccination of teenagers and young adults, applying the more recent cancer costs reduced the estimated cost per QALY gained by about $12,400. The cost studies we identified in our literature review are up-to-date and based on reliable data sources from United States settings, and can inform future studies of HPV vaccination cost-effectiveness in the United States. However, careful consideration is warranted to determine the most appropriate cost values to apply.

Cost-effectiveness of breast cancer screening in the National Breast and Cervical Cancer Early Detection Program

PURPOSE

To estimate the cost-effectiveness of breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

METHODS

Using a modified CISNET breast cancer simulation model, we estimated outcomes for women aged 40-64 years associated with three scenarios: breast cancer screening within the NBCCEDP, screening in the absence of the NBCCEDP (no program), and no screening through any program. We report screening outcomes, cost, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and sensitivity analyses results.

RESULTS

Compared with no program and no screening, the NBCCEDP lowers breast cancer mortality and improves QALYs, but raises health care costs. Base-case ICER for the program was $51,754/QALY versus no program and $50,223/QALY versus no screening. Probabilistic sensitivity analysis ICER for the program was $56,615/QALY [95% CI $24,069, $134,230/QALY] versus no program and $51,096/QALY gained [95% CI $26,423, $97,315/QALY] versus no screening.

CONCLUSIONS

On average, breast cancer screening in the NBCCEDP was cost-effective compared with no program or no screening.

Population-based cancer screening programmes in low-income and middle-income countries: regional consultation of the International Cancer Screening Network in India

The reductions in cancer morbidity and mortality afforded by population-based cancer screening programmes have led many low-income and middle-income countries to consider the implementation of national screening programmes in the public sector. Screening at the population level, when planned and organised, can greatly benefit the population, whilst disorganised screening can increase costs and reduce benefits. The International Cancer Screening Network (ICSN) was created to share lessons, experience, and evidence regarding cancer screening in countries with organised screening programmes. Organised screening programmes provide screening to an identifiable target population and use multidisciplinary delivery teams, coordinated clinical oversight committees, and regular review by a multidisciplinary evaluation board to maximise benefit to the target population. In this Series paper, we report outcomes of the first regional consultation of the ICSN held in Agartala, India (Sept 5-7, 2016), which included discussions from cancer screening programmes from Denmark, the Netherlands, USA, and Bangladesh. We outline six essential elements of population-based cancer screening programmes, and share recommendations from the meeting that policy makers might want to consider before implementation.

The Need for Societal Investment to Improve Cervical Cancer Outcomes in Nigeria: A commentary

Although cervical cancer is a preventable cancer with a well-known natural history, it remains a huge burden in developing countries of sub-Saharan Africa where organized cervical cancer screening services are lacking. Developed countries that have invested on providing organized screening programs have made substantial progress in reducing both incidence and mortality due to cervical cancer. Implementing evidence-based interventions such as human papillomavirus (HPV) vaccination of young girls, early detection and treatment of premalignant conditions of the cervix through conventional Pap cytology, HPV screening or visual aided inspection with acetic acid could significantly reduce incidence of new cases at population level. Societal investment for such preventive services and provision of effective treatment for those diagnosed at early stages will yield economic benefits in reducing premature deaths of women at the prime of their productive lives. From a societal perspective, this should be a priority area for national investment towards the achievement of sustainable development in Nigeria and similar settings in Africa.

Costs of colorectal cancer screening provision in CDC's Colorectal Cancer Control Program: Comparisons of colonoscopy and FOBT/FIT based screening

We assess annual costs of screening provision activities implemented by 23 of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP) grantees and report differences in costs between colonoscopy and FOBT/FIT-based screening programs. We analysed annual cost data for the first three years of the CRCCP (July 2009-June 2011) for each screening provision activity and categorized them into clinical and non-clinical screening provision activities. The largest cost components for both colonoscopy and FOBT/FIT-based programs were screening and diagnostic services, program management, and data collection and tracking. During the first 3 years of the CRCCP, the average annual clinical cost for screening and diagnostic services per person served was $1150 for colonoscopy programs, compared to $304 for FIT/FOBT-based programs. Overall, FOBT/FIT-based programs appear to have slightly higher non-clinical costs per person served (average $1018; median $838) than colonoscopy programs (average $980; median $686). Colonoscopy-based CRCCP programs have higher clinical costs than FOBT/FIT-based programs during the 3-year study timeframe (translating into fewer people screened). Non-clinical costs for both approaches are similar and substantial. Future studies of the cost-effectiveness of colorectal cancer screening initiatives should consider both clinical and non-clinical costs.

Reported breast symptoms in the National Breast and Cervical Cancer Early Detection Program

PURPOSE

The frequency and types of breast symptoms reported by women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) have never been characterized. This study aims to establish the frequency of reported symptoms and the diagnostic outcomes associated with reported symptoms.

METHODS

We examined the frequency of symptoms reported prior to mammography using medical record abstraction data from women in the NBCCEDP. We also calculated adjusted odds ratios (aOR) of having an abnormal mammogram, an abnormal clinical breast examination, or a final diagnosis of breast cancer by symptoms, compared to asymptomatic women.

RESULTS

In our sample of women, 10.3 % reported at least one symptom. Women with symptoms were younger and more likely to be non-Hispanic white. Among those reporting symptoms, breast lump (31.7 %) and pain or tenderness (49.3 %) was most common. A relatively low proportion of women with symptoms were diagnosed with in situ (0.9 %) or invasive breast cancer (4.3 %). However, a self-reported breast lump [aOR 13.7; 95 % confidence interval (CI) 7.8-24.1], inflammation or changes to the skin/nipple (aOR 27.8; 95 % CI 8.7-88.8), and other or unspecified symptoms (aOR 3.4; 95 % CI 2.1-7.5) were associated with an increased risk of invasive breast cancer.

CONCLUSIONS

Although the prevalence of breast cancer among women reporting symptoms is relatively low, knowing which symptoms carry the highest breast cancer risk is important to assist in appropriate diagnostic workup.