Cost-effectiveness of MR-mammography vs. conventional mammography in screening patients at intermediate risk of breast cancer - A model-based economic evaluation

Maintaining accuracy and expanding access: evaluating the efficacy of the Botucatu Abbreviated Breast MRI Protocol

Objective

Our study evaluated the effectiveness of the Botucatu Abbreviated Protocol in breast magnetic resonance imaging (MRI) within Brazil's public healthcare system, focusing on its impact on patient access to MRI exams.

Methods

This retrospective study involved 197 breast MRI exams of female patients over 18 years with histological breast carcinoma diagnosis, conducted at Hospital das Clínicas de Botucatu - UNESP between 2014 and 2018. Two experienced examiners prospectively and blindly analyzed the exams using an Integrated Picture Archiving and Communication System (PACS). They first evaluated the Botucatu Abbreviated Protocol, created from sequences of the complete protocol (PC), and after an average interval of 30 days, they reassessed the same 197 exams with the complete protocol. Dynamic and morphological characteristics of lesions were assessed according to BI-RADS 5th edition criteria. The study also analyzed the average number of monthly exams before and after the implementation of Botucatu Abbreviated Protocol.

Results

The Botucatu Abbreviated Protocol showed high sensitivity (99% and 96%) and specificity (90.9% and 96%). There was a significant increase in the average monthly MRI exams from 6.62 to 23.8 post-implementation.

Conclusion

The Botucatu Abbreviated Protocol proved effective in maintaining diagnostic accuracy and improving accessibility to breast MRI exams, particularly in the public healthcare setting.

Auditing Abbreviated Breast MR Imaging: Clinical Considerations and Implications

Abbreviated breast MR (AB-MR) imaging is a relatively new breast imaging tool, which maintains diagnostic accuracy while reducing image times compared with full-protocol breast MR (FP-MR) imaging. Breast imaging audits involve calculating individual and organizational metrics, which can be compared with established benchmarks, providing a standard against which performance can be measured. Unlike FP-MR imaging, there are no established benchmarks for AB-MR imaging but studies demonstrate comparable performance for cancer detection rate, positive predictive value 3, sensitivity, and specificity with T2. We review the basics of performing an audit, including strategies to implement if benchmarks are not being met.

Economic evaluation of breast MRI in screening - a systematic review and basic approach to cost-effectiveness analyses

Background

Economic evaluations have become an accepted methodology for decision makers to allocate resources in healthcare systems. Particularly in screening, where short-term costs are associated with long-term benefits, and adverse effects of screening intermingle, cost-effectiveness analyses provide a means to estimate the economic value of screening.

Purpose

To introduce the methodology of economic evaluations and to review the existing evidence on cost-effectiveness of MR-based breast cancer screening.

Materials and methods

The various concepts and techniques of economic evaluations critical to the interpretation of cost-effectiveness analyses are briefly introduced. In a systematic review of the literature, economic evaluations from the years 2000-2022 are reviewed.

Results

Despite a considerable heterogeneity in the reported input variables, outcome categories and methodological approaches, cost-effectiveness analyses report favorably on the economic value of breast MRI screening for different risk groups, including both short- and long-term costs and outcomes.

Conclusion

Economic evaluations indicate a strongly favorable economic value of breast MRI screening for women at high risk and for women with dense breast tissue.

Mathematical Analysis of the Effectiveness of Screening for Intracranial Aneurysms in First-Degree Relatives of Persons with Subarachnoid Hemorrhage

OBJECTIVE

Population screening for aneurysms in patients with risk factors and preventive surgical treatment are beneficial according to numerous studies. One of the most significant risk factors is heredity, namely, the presence of first-degree relatives (FDR) with aneurysmal subarachnoid hemorrhage (aSAH). Nevertheless, there are still no generally accepted approaches or evidence bases regarding the benefits of the aneurysm screening strategy.

METHODS

Mathematical modeling of the dynamics of aneurysm development in the population was carried out using an algorithm implementing a discrete Markov's chain. To implement the model, all probabilities of events and distributions are taken from available literature sources. Three-dimensional time of flight noncontrast magnetic resonance angiography was chosen as a screening method. Patients underwent preventive surgical treatment if an aneurysm was detected.

RESULTS

Screening and preventive treatment in the general population reduces the prevalence of aneurysms by 1.74% (3.44% in the FDR group) and the prevalence of aSAH by 14.36% (37.48% in the FDR group). Mortality due to aSAH was reduced by 14.44%. The number of disabilities also decreases. The occurrence of deep disability was reduced by 20.2% in the FDR group. Economic analysis of the part of the population consisting of FDRs showed annual savings of ies also decr CONCLUSIONS: The mathematical model demonstrated that screening and preventive treatment of cerebral aneurysms can reduce aSAH-associated morbidity and mortality. In the FDR group, there was decrease in the prevalence of aSAH and decrease in associated mortality. Screening for cerebral aneurysms is cost-effective.

[Screening of patients with cerebral aneurysms: mathematical analysis and economic justification]

Subarachnoid hemorrhages due to rupture of cerebral aneurysms have a high risk of disability and mortality. Screening of the population to detect aneurysms in patients with risk factors is currently not carried out in Russia. However, the detection of clinically silent aneurysms and their subsequent prophylactic surgical treatment are justified, according to numerous studies.

BACKGROUND

Demonstrate the clinical and economic feasibility of screening the population (including first-line relatives) for cerebral aneurysms using an economic and mathematical model of the RF virtual population.

MATERIAL AND METHODS

Mathematical modeling was carried out using an algorithm that implements a discrete Markov chain. The virtual population consisted of 145 million people (the population of the Russian Federation). Magnetic resonance angiography 3DTOF was chosen as a screening method. Virtual patients underwent preventive surgical treatment in case of detection of aneurysm during screening. The number of aneurysms in the population, the number of aneurysmal subarachnoid hemorrhage (aSAH), the cost and outcomes of treatment, and the risk of disability were calculated.

RESULTS

In the case of screening and preventive surgical treatment of aneurysms, there is a decrease in the number of aSAH by 14.3% (37.5% in first-line relatives (RPLR), which affects the reduction in mortality due to aSAH by 14.4% (24.1% in The total number of disabled people is reduced by 1.5% (5.1% for the RPHR). A shift in the structure of disability towards greater labor and social adaptation of patients was noted. An economic analysis for the entire population showed that screening saves 7.7 billion annually rubles, including in the population consisting of RPLR - 4.9 billion rubles.

CONCLUSION

The created mathematical model of the virtual population demonstrated that screening and prophylactic treatment of cerebral aneurysms makes it possible to reduce the number of aSAH and associated mortality among the entire population and in the RPLR group. The number of individuals with severe disabilities is decreasing. Thus, population screening for the detection of cerebral aneurysms may be clinically effective and cost-effective in the general population, especially in RPCR.

Breast MRI: does a clinical decision algorithm outweigh reader experience?

Objectives

Due to its high sensitivity, DCE MRI of the breast (MRIb) is increasingly used for both screening and assessment purposes. The Kaiser score (KS) is a clinical decision algorithm, which formalizes and guides diagnosis in breast MRI and is expected to compensate for lesser reader experience. The aim was to evaluate the diagnostic performance of untrained residents using the KS compared to off-site radiologists experienced in breast imaging using only MR BI-RADS.

Methods

Three off-site, board-certified radiologists, experienced in breast imaging, interpreted MRIb according to the MR BI-RADS scale. The same studies were read by three residents in radiology without prior training in breast imaging using the KS. All readers were blinded to clinical information. Histology was used as the gold standard. Statistical analysis was conducted by comparing the AUC of the ROC curves.

Results

A total of 80 women (median age 52 years) with 93 lesions (32 benign, 61 malignant) were included. The individual within-group performance of the three expert readers (AUC 0.723–0.742) as well as the three residents was equal (AUC 0.842–0.928), p > 0.05, respectively. But, the rating of each resident using the KS significantly outperformed the experts’ ratings using the MR BI-RADS scale (p ≤ 0.05).

Conclusion

The KS helped residents to achieve better results in reaching correct diagnoses than experienced radiologists empirically assigning MR BI-RADS categories in a clinical “problem solving MRI” setting. These results support that reporting breast MRI benefits more from using a diagnostic algorithm rather than expert experience.

Key Points

• Reporting breast MRI benefits more from using a diagnostic algorithm rather than expert experience in a clinical “problem solving MRI” setting.

• The Kaiser score, which provides a clinical decision algorithm for structured reporting, helps residents to reach an expert level in breast MRI reporting and to even outperform experienced radiologists using MR BI-RADS without further formal guidance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-022-09015-8.

Evidence-Based and Structured Diagnosis in Breast MRI using the Kaiser Score

BACKGROUND

 Breast MRI is the most sensitive method for the detection of breast cancer and is an integral part of modern breast imaging. On the other hand, interpretation of breast MRI exams is considered challenging due to the complexity of the available information. Clinical decision rules that combine diagnostic criteria in an algorithm can help the radiologist to read breast MRI by supporting objective and largely experience-independent diagnosis.

METHOD

 Narrative review. In this article, the Kaiser Score (KS) as a clinical decision rule for breast MRI is introduced, its diagnostic criteria are defined, and strategies for clinical decision making using the KS are explained and discussed.

RESULTS

 The KS is based on machine learning and has been independently validated by international research. It is largely independent of the examination technique that is used. It allows objective differentiation between benign and malignant contrast-enhancing breast MRI findings using diagnostic BI-RADS criteria taken from T2w and dynamic contrast-enhanced T1w images. A flowchart guides the reader in up to three steps to determine a score corresponding to the probability of malignancy that can be used to assign a BI-RADS category. Individual decision making takes the clinical context into account and is illustrated by typical scenarios.

KEY POINTS

· The KS as an evidence-based decision rule to objectively distinguish benign from malignant breast lesions is based on information contained in T2w und dynamic contrast-enhanced T1w sequences and is largely independent of specific examination protocols.. · The KS diagnostic criteria are in line with the MRI BI-RADS lexicon. We focused on defining a default category to be applied in the case of equivocal imaging criteria.. · The KS reflects increasing probabilities of malignancy and, together with the clinical context, assists individual decision making..

CITATION FORMAT

· Baltzer PA, Krug KB, Dietzel M. Evidence-Based and Structured Diagnosis in Breast MRI using the Kaiser Score. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1829-5985.

Screening MRI in Women at Intermediate Breast Cancer Risk: An Update of the Recent Literature

Guidelines issued by the American Cancer Society (ACS) in 2007 recommend neither for nor against screening MRI in women at intermediate breast cancer risk (15%-20%), including those with dense breast tissue, a history of lobular neoplasia or atypical ductal hyperplasia (ADH), or a prior breast cancer, because of scarce supporting evidence about the utility of MRI in these specific patient populations. However, since the issuance of the ACS guidelines in 2007, multiple investigations have found that women at intermediate risk may be suitable candidates for screening MRI, given the high detection rates of early-stage cancers and acceptable false-positive rates. For women with dense breast tissue, the Dense Tissue and Early Breast Neoplasm Screening trial reported that the incremental cancer detection rate (CDR) by MRI exceeded 16 cancers per 1000 examinations but decreased in the second round of screening; this decrease in CDR, however, occurred alongside a marked decrease in the false-positive rate. For women with lobular neoplasia or ADH, single-institution retrospective analyses have shown CDRs mostly ranging from 11 to 16 cancers per 1000 MRI examinations, with women with lobular carcinoma in situ benefitting more than women with atypical lobular hyperplasia or ADH. For patients with a prior breast cancer, the cancer yield by MRI varies widely but mostly ranges from 8 to 20 cancers per 1000 examinations, with certain subpopulations more likely to benefit, such as those with dense breasts. This article reviews and summarizes more recent studies on MRI screening of intermediate-risk women.

Economic potential of abbreviated breast MRI for screening women with dense breast tissue for breast cancer

OBJECTIVES

Abbreviated breast MRI (AB-MRI) was introduced to reduce both examination and image reading times and to improve cost-effectiveness of breast cancer screening. The aim of this model-based economic study was to analyze the cost-effectiveness of full protocol breast MRI (FB-MRI) vs. AB-MRI in screening women with dense breast tissue for breast cancer.

METHODS

Decision analysis and a Markov model were designed to model the cumulative costs and effects of biennial screening in terms of quality-adjusted life years (QALYs) from a US healthcare system perspective. Model input parameters for a cohort of women with dense breast tissue were adopted from recent literature. The impact of varying AB-MRI costs per examination as well as specificity on the resulting cost-effectiveness was modeled within deterministic sensitivity analyses.

RESULTS

At an assumed cost per examination of $ 263 for AB-MRI (84% of the cost of a FB-MRI examination), the discounted cumulative costs of both MR-based strategies accounted comparably. Reducing the costs of AB-MRI below $ 259 (82% of the cost of a FB-MRI examination, respectively), the incremental cost-effectiveness ratio of FB-MRI exceeded the willingness to pay threshold and the AB-MRI-strategy should be considered preferable in terms of cost-effectiveness.

CONCLUSIONS

Our preliminary findings indicate that AB-MRI may be considered cost-effective compared to FB-MRI for screening women with dense breast tissue for breast cancer, as long as the costs per examination do not exceed 82% of the cost of a FB-MRI examination.

KEY POINTS

• Cost-effectiveness of abbreviated breast MRI is affected by reductions in specificity and resulting false positive findings and increased recall rates. • Abbreviated breast MRI may be cost-effective up to a cost per examination of 82% of the cost of a full protocol examination. • Abbreviated breast MRI could be an economically preferable alternative to full protocol breast MRI in screening women with dense breast tissue.

Cost-effectiveness of abbreviated-protocol MRI screening for women with mammographically dense breasts in a national breast cancer screening program

Introduction

Magnetic resonance imaging (MRI) has shown the potential to improve the screening effectiveness among women with dense breasts. The introduction of fast abbreviated protocols (AP) makes MRI more feasible to be used in a general population. We aimed to investigate the cost-effectiveness of AP-MRI in women with dense breasts (heterogeneously/extremely dense) in a population-based screening program.

Methods

A previously validated model (SiMRiSc) was applied, with parameters updated for women with dense breasts. Breast density was assumed to decrease with increased age. The base scenarios included six biennial AP-MRI strategies, with biennial mammography from age 50–74 as reference. Fourteen alternative scenarios were performed by varying screening interval (triennial and quadrennial) and by applying a combined strategy of mammography and AP-MRI. A 3% discount rate for both costs and life years gained (LYG) was applied. Model robustness was evaluated using univariate and probabilistic sensitivity analyses.

Results

The six biennial AP-MRI strategies ranged from 132 to 562 LYG per 10,000 women, where more frequent application of AP-MRI was related to higher LYG. The optimal strategy was biennial AP-MRI screening from age 50–65 for only women with extremely dense breasts, producing an incremental cost-effectiveness ratio of € 18,201/LYG. At a threshold of € 20,000/LYG, the probability that the optimal strategy was cost-effective was 79%.

Conclusion

Population-based biennial breast cancer screening with AP-MRI from age 50–65 for women with extremely dense breasts might be a cost-effective alternative to mammography, but is not an option for women with heterogeneously dense breasts.

•

AP-MRI can be cost-effective for screening women with extremely dense breast.

•

The more frequent the use of AP-MRI, the more life years will be gained.

•

Biennial AP-MRI for women with extremely dense breast up to age 65 is optimal.

Cost-Effectiveness of MR-Mammography in Breast Cancer Screening of Women With Extremely Dense Breasts After Two Rounds of Screening

Objectives

To evaluate the cost-effectiveness of MR-mammography (MRM) vs. x-ray based mammography (XM) in two-yearly screening women of intermediate risk for breast cancer in the light of recent literature.

Methods

Decision analysis and Markov modelling were used to compare cumulative costs (in US-$) and outcomes (in QALYs) of MRM vs. XM over the model runtime of 20 years. The perspective of the U.S. healthcare system was selected. Incremental cost-effectiveness ratios (ICER) were calculated and related to a willingness to pay-threshold of $ 100,000 per QALY in order to evaluate the cost-effectiveness. Deterministic and probabilistic sensitivity analyses were conducted to test the impact of variations of the input parameters. In particular, variations of the rate of false positive findings beyond the first screening round and their impact on cost-effectiveness were assessed.

Results

Breast cancer screening with MRM resulted in increased costs and superior effectiveness. Cumulative average costs of $ 6,081 per woman and cumulative effects of 15.12 QALYs were determined for MRM, whereas screening with XM resulted in costs of $ 5,810 and 15.10 QALYs, resulting in an ICER of $ 13,493 per QALY gained. When the specificity of MRM in the second and subsequent screening rounds was varied from 92% to 99%, the ICER resulted in a range from $ 38,849 to $ 5,062 per QALY.

Conclusions

Based on most recent data on the diagnostic performance beyond the first screening round, MRM may remain the economically preferable alternative in screening women of intermediate risk for breast cancer due to their dense breast tissue.

Cost-Effectiveness of Digital Breast Tomosynthesis vs. Abbreviated Breast MRI for Screening Women with Intermediate Risk of Breast Cancer-How Low-Cost Must MRI Be?

BACKGROUND

Digital breast tomosynthesis (DBT) and abbreviated breast MRI (AB-MRI) offer superior diagnostic performance compared to conventional mammography in screening women with intermediate risk of breast cancer due to dense breast tissue. The aim of this model-based economic evaluation was to analyze whether AB-MRI is cost-effective in this cohort compared to DBT.

METHODS

Decision analysis and Markov simulations were used to model the cumulative costs and quality-adjusted life-years (QALYs) over a time horizon of 30 years. Model input parameters were adopted from recent literature. Deterministic and probabilistic sensitivity analyses were applied to test the stability of the model.

RESULTS

In the base-case scenario, the costs of an AB-MRI examination were defined to equal the costs of a full protocol acquisition. Two-yearly screening of women with dense breasts resulted in cumulative discounted costs of $8798 and $9505 for DBT and AB-MRI, and cumulative discounted effects of 19.23 and 19.27 QALYs, respectively, with an incremental cost-effectiveness ratio of $20,807 per QALY gained in the base-case scenario. By reducing the cost of an AB-MRI examination below a threshold of $241 in sensitivity analyses, AB-MRI would become cost-saving compared to DBT.

CONCLUSION

In comparison to DBT, AB-MRI can be considered cost-effective up to a price per examination of $593 in screening patients at intermediate risk of breast cancer.

Screening for Intracranial Aneurysms in Individuals with a Positive First-Degree Family History: A Systematic Review

BACKGROUND

Subarachnoid hemorrhage secondary to rupture of an intracranial aneurysm (IA) is a devastating condition with high morbidity and mortality. Individuals with a positive family history of aneurysmal subarachnoid hemorrhage (aSAH) or IA can have an increased risk for aSAH or IA themselves. Screening is currently recommended in families with ≥2 affected first-degree relatives. We sought to assess the usefulness and cost-effectiveness of IA screening in individuals with a positive first-degree family history, relative to the number of family members affected.

METHODS

We performed a systematic literature search using PubMed and Google Scholar and identified additional studies by reviewing reference lists. Only original studies and review papers were considered. We excluded genetic diseases associated with IA and studies with unclear data concerning the number of first-versus second-degree relatives affected.

RESULTS

This review included 37 articles. Individuals with ≥2 affected first-degree relatives had a greater prevalence of IA (average 13.1% vs. 3% in the general population). Similarly, we found a greater prevalence of IA in individuals with ≥1 affected first-degree relative (average 4.8%, up to 19% in individuals with additional risk factors). The risk of aSAH also was increased in both categories. Recent studies stressed the importance of serial screening over time and suggested that such screening can be cost-effective in persons with only one first-degree relative with IA or aSAH.

CONCLUSIONS

While current guidelines do not recommend screening individuals with ≥1 first-degree relative affected, we found strong arguments in favor of this approach.

[Artificial intelligence in breast imaging : Areas of application from a clinical perspective]

Klinisches/methodisches Problem

Bei der Mammadiagnostik gilt es, klinische sowie multimodal bildgebende Informationen mit perkutanen und operativen Eingriffen zu koordinieren. Aus dieser Komplexität entsteht eine Reihe von Problemen: übersehene Karzinome, Überdiagnose, falsch-positive Befunde, unnötige weiterführende Bildgebung, Biopsien und Operationen.

Radiologische Standardverfahren

Folgende Untersuchungsverfahren werden in der Mammadiagnostik eingesetzt: Röntgenmammographie, Tomosynthese, kontrastangehobene Mammographie, (multiparametrischer) Ultraschall, Magnetresonanztomographie, Computertomographie, nuklearmedizinische Verfahren sowie deren Hybridvarianten.

Methodische Innovationen

Künstliche Intelligenz (KI) verspricht Abhilfe bei praktisch allen Problemen der Mammadiagnostik. Potenziell lassen sich Fehlbefunde vermeiden, bildgebende Verfahren effizienter einsetzen und möglicherweise auch biologische Phänotypen von Mammakarzinomen definieren.

Leistungsfähigkeit

Auf KI basierende Software wird für zahlreiche Anwendungen entwickelt. Am weitesten fortgeschritten sind Systeme für das Screening mittels Mammographie. Probleme sind monozentrische sowie kurzfristig am finanziellen Erfolg orientierte Ansätze.

Bewertung

Künstliche Intelligenz (KI) verspricht eine Verbesserung der Mammadiagnostik. Durch die Vereinfachung von Abläufen, die Reduktion monotoner und ergebnisloser Tätigkeiten und den Hinweis auf mögliche Fehler ist eine Beschleunigung von dann weitgehend fehlerfreien Abläufen denkbar.

Empfehlung für die Praxis

In diesem Beitrag werden die Anforderungen der Mammadiagnostik und mögliche Einsatzgebiete der der KI beleuchtet. Je nach Definition gibt es bereits praktisch anwendbare Softwaretools für die Mammadiagnostik. Globale Lösungen stehen allerdings noch aus.

Abbreviated magnetic resonance imaging in breast cancer: A systematic review of literature

BACKGROUND

: magnetic resonance imaging (MRI) has been increasingly used to study breast cancer for screening high-risk cases, pre-operative staging, and problem-solving because of its high sensitivity. However, its cost-effectiveness is still debated. Thus, the concept of abbreviated MRI (ABB-MRI) protocols was proposed as a possible solution for reducing MRI costs.

PURPOSE

: to investigate the role of the abbreviated MRI protocols in detecting and staging breast cancer.

METHODS

: a systematic search of the literature was carried out in the bibliographic databases: Scopus, PubMed, Medline, and Science Direct.

RESULTS

: forty-one articles were included, which described results of the assessment of fifty-three abbreviated protocols for screening, staging, recurrence assessing, and problem-solving or clarification.

CONCLUSIONS

: the use of ABB-MRI protocols allows reducing the acquisition and reading times, maintaining a high concordance with the final interpretation, in comparison to a complete protocol. However, larger prospective and multicentre trials are necessary to validate the performance in specific clinical environments.