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Pillay J, Guitard S, Rahman S, Saba S, Rahman A, Bialy L, Gehring N, Tan M, Melton A, Hartling L. Patient preferences for breast cancer screening: a systematic review update to inform recommendations by the Canadian Task Force on Preventive Health Care. Syst Rev 2024; 13:140. [PMID: 38807191 PMCID: PMC11134964 DOI: 10.1186/s13643-024-02539-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/17/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Different guideline panels, and individuals, may make different decisions based in part on their preferences. Preferences for or against an intervention are viewed as a consequence of the relative importance people place on the expected or experienced health outcomes it incurs. These findings can then be considered as patient input when balancing effect estimates on benefits and harms reported by empirical evidence on the clinical effectiveness of screening programs. This systematic review update examined the relative importance placed by patients on the potential benefits and harms of mammography-based breast cancer screening to inform an update to the 2018 Canadian Task Force on Preventive Health Care's guideline on screening. METHODS We screened all articles from our previous review (search December 2017) and updated our searches to June 19, 2023 in MEDLINE, PsycINFO, and CINAHL. We also screened grey literature, submissions by stakeholders, and reference lists. The target population was cisgender women and other adults assigned female at birth (including transgender men and nonbinary persons) aged ≥ 35 years and at average or moderately increased risk for breast cancer. Studies of patients with breast cancer were eligible for health-state utility data for relevant outcomes. We sought three types of data, directly through (i) disutilities of screening and curative treatment health states (measuring the impact of the outcome on one's health-related quality of life; utilities measured on a scale of 0 [death] to 1 [perfect health]), and (ii) other preference-based data, such as outcome trade-offs, and indirectly through (iii) the relative importance of benefits versus harms inferred from attitudes, intentions, and behaviors towards screening among patients provided with estimates of the magnitudes of benefit(s) and harms(s). For screening, we used machine learning as one of the reviewers after at least 50% of studies had been reviewed in duplicate by humans; full-text selection used independent review by two humans. Data extraction and risk of bias assessments used a single reviewer with verification. Our main analysis for utilities used data from utility-based health-related quality of life tools (e.g., EQ-5D) in patients; a disutility value of about 0.04 can be considered a minimally important value for the Canadian public. When suitable, we pooled utilities and explored heterogeneity. Disutilities were calculated for screening health states and between different treatment states. Non-utility data were grouped into categories, based on outcomes compared (e.g. for trade-off data), participant age, and our judgements of the net benefit of screening portrayed by the studies. Thereafter, we compared and contrasted findings while considering sample sizes, risk of bias, subgroup findings and data on knowledge scores, and created summary statements for each data set. Certainty assessments followed GRADE guidance for patient preferences and used consensus among at least two reviewers. FINDINGS Eighty-two studies (38 on utilities) were included. The estimated disutilities were 0.07 for a positive screening result (moderate certainty), 0.03-0.04 for a false positive (FP; "additional testing" resolved as negative for cancer) (low certainty), and 0.08 for untreated screen-detected cancer (moderate certainty) or (low certainty) an interval cancer. At ≤12 months, disutilities of mastectomy (vs. breast-conserving therapy), chemotherapy (vs. none) (low certainty), and radiation therapy (vs. none) (moderate certainty) were 0.02-0.03, 0.02-0.04, and little-to-none, respectively, though in each case findings were somewhat limited in their applicability. Over the longer term, there was moderate certainty for little-to-no disutility from mastectomy versus breast-conserving surgery/lumpectomy with radiation and from radiation. There was moderate certainty that a majority (>50%) and possibly a large majority (>75%) of women probably accept up to six cases of overdiagnosis to prevent one breast-cancer death; there was some uncertainty because of an indication that overdiagnosis was not fully understood by participants in some cases. Low certainty evidence suggested that a large majority may accept that screening may reduce breast-cancer but not all-cause mortality, at least when presented with relatively high rates of breast-cancer mortality reductions (n = 2; 2 and 5 fewer per 1000 screened), and at least a majority accept that to prevent one breast-cancer death at least a few hundred patients will receive a FP result and 10-15 will have a FP resolved through biopsy. An upper limit for an acceptable number of FPs was not evaluated. When using data from studies assessing attitudes, intentions, and screening behaviors, across all age groups but most evident for women in their 40s, preferences reduced as the net benefit presented by study authors decreased in magnitude. In a relatively low net-benefit scenario, a majority of patients in their 40s may not weigh the benefits as greater than the harms from screening whereas for women in their 50s a large majority may prefer screening (low certainty evidence for both ages). There was moderate certainty that a large majority of women 50 years of age and 50 to 69 years of age, who have usually experienced screening, weigh the benefits as greater than the harms from screening in a high net-benefit scenario. A large majority of patients aged 70-71 years who have recently screened probably think the benefits outweigh the harms of continuing to screen. A majority of women in their mid-70s to early 80s may prefer to continue screening. CONCLUSIONS Evidence across a range of data sources on how informed patients value the potential outcomes from breast-cancer screening will be useful during decision-making for recommendations. The evidence suggests that all of the outcomes examined have importance to women of any age, that there is at least some and possibly substantial (among those in their 40s) variability across and within age groups about the acceptable magnitude of effects across outcomes, and that provision of easily understandable information on the likelihood of the outcomes may be necessary to enable informed decision making. Although studies came from a wide range of countries, there were limited data from Canada and about whether findings applied well across an ethnographically and socioeconomically diverse population. SYSTEMATIC REVIEW REGISTRATION Protocol available at Open Science Framework https://osf.io/xngsu/ .
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Affiliation(s)
- Jennifer Pillay
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada.
| | - Samantha Guitard
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Sholeh Rahman
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Sabrina Saba
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Ashiqur Rahman
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Liza Bialy
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Nicole Gehring
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Maria Tan
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Alex Melton
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
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Tollens F, Baltzer PA, Froelich MF, Kaiser CG. Economic evaluation of breast MRI in screening - a systematic review and basic approach to cost-effectiveness analyses. Front Oncol 2023; 13:1292268. [PMID: 38130995 PMCID: PMC10733447 DOI: 10.3389/fonc.2023.1292268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
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.
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Affiliation(s)
- Fabian Tollens
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Pascal A.T. Baltzer
- Department of Biomedical Imaging and Image-Guided Therapy, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Matthias F. Froelich
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Clemens G. Kaiser
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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Yeong SW, Lee SW, Ong SC. Cost-Effectiveness of Breast Cancer Early Detection Program in Low- and Middle-Income Countries: A Systematic Review. Value Health Reg Issues 2023; 35:57-68. [PMID: 36870173 DOI: 10.1016/j.vhri.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 10/19/2022] [Accepted: 01/20/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVES This review explores the cost-effectiveness of the strategies used in the breast cancer early detection programs of low- to middle-income countries. METHODS A systematic review was performed to identify related studies, published up to August 2021, on PubMed, Cochrane, ProQuest, and the Cumulative Index to Nursing and Allied Health Literature. The Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol were referenced during the reporting process. The Consolidated Health Economic Evaluation Reporting Standards 2022 criteria were used to assess the requirements of the selected studies. Articles with original data and full texts were included in the review. Non-low- to middle-income countries and non-English articles were excluded. RESULTS This review identified 12 suitable studies, wherein 6 investigated the cost-effectiveness of clinical breast examinations (CBEs), whereas 10 looked into mammogram (MMG) with or without CBE. In 2 studies, the cost-effectiveness of raising awareness through mass media and the use of ultrasounds combined with CBE were investigated. Although cost-effective, MMG incurs greater costs and requires more skill to be performed. MMG screenings before the age of 40 years were not cost-effective. The limitations of this review include variability in the methodological approaches of its selected studies. Most of the chosen studies met the Consolidated Health Economic Evaluation Reporting Standards 2022 criteria. CONCLUSIONS This review shows that adopting an age- and risk-based MMG screening approach could be viable in countries with limited resources. Future cost-effectiveness analysis research should include a section on patient and stakeholder engagement with the study's results.
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Affiliation(s)
- Siew Wei Yeong
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia; Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia
| | - Sit Wai Lee
- Malaysian Health Technology Assessment Section, Medical Development Division, Ministry of Health Malaysia, Putrajaya, Malaysia
| | - Siew Chin Ong
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia.
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Li G, Xia YF, Huang YX, Okat D, Qiu B, Doyen J, Bondiau PY, Benezery K, Gao J, Qian CN. Cost-effectiveness of using protons for breast irradiation aiming at minimizing cardiotoxicity: A risk-stratification analysis. Front Med (Lausanne) 2022; 9:938927. [PMID: 36091675 PMCID: PMC9452743 DOI: 10.3389/fmed.2022.938927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/02/2022] [Indexed: 11/23/2022] Open
Abstract
Background Incidental exposure of the heart to ionizing irradiation is associated with an increased risk of ischemic heart disease and subsequent fatality in patients with breast cancer after radiotherapy. Proton beam therapy can limit the heart dose in breast irradiation to a negligible level. However, compared with conventional photon modality, proton breast irradiation is more expensive. In this study, we performed cost-effectiveness analyses to identify the type of patients who would be more suitable for protons. Methods A Markov decision model was designed to evaluate the cost-effectiveness of protons vs. photons in reducing the risk of irradiation-related ischemic heart disease. A baseline evaluation was performed on a 50-year-old woman patient without the preexisting cardiac risk factor. Furthermore, risk-stratification analyses for photon mean heart dose and preexisting cardiac risk were conducted on 40-, 50-, and 60-year-old women patients under different proton cost and willingness-to-pay (WTP) settings. Results Using the baseline settings, the incremental effectiveness (protons vs. photons) increased from 0.043 quality-adjusted life-year (QALY) to 0.964 QALY when preexisting cardiac risk increased to 10 times its baseline level. At a proton cost of 50,000 US dollars ($), protons could be cost-effective for ≤ 60-year-old patients with diabetes and ≤50-year-old patients with grade II–III hypertension at the WTP of China ($37,653/QALY); for ≤ 60-year-old patients with diabetes and ≤ 50-year-old patients with grade II–III hypertension or ≥ 2 major cardiac risk factors at a WTP of $50,000/QALY; and for ≤ 60-year-old patients with diabetes, grade II–III hypertension or ≥ 2 major cardiac risk factors and ≤ 50-year-old patients with total cholesterol ≥ 240 mg/dL at a WTP of $100,000/QALY. Conclusion Patients' preexisting cardiac risk status was a key factor affecting the cardiac benefits gained from protons and should therefore be a major consideration for the clinical decision of using protons; cost-effective scenarios of protons exist in those patients with high risk of developing cardiac diseases.
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Affiliation(s)
- Guo Li
- Department of Radiation Oncology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
- Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, China
| | - Yun-Fei Xia
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yi-Xiang Huang
- Department of Health Management, Public Health Institute of Sun Yat-sen University, Guangzhou, China
| | - Deniz Okat
- Department of Finance, Hong Kong University of Science and Technology, Kowloon, Hong Kong SAR, China
| | - Bo Qiu
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jerome Doyen
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
- Mediterranean Institute of Proton Therapy, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Pierre-Yves Bondiau
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
- Mediterranean Institute of Proton Therapy, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Karen Benezery
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
- Mediterranean Institute of Proton Therapy, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Jin Gao
- Division of Life Sciences and Medicine, Department of Radiation Oncology, The First Affiliated Hospital of University of Science and Technology of China, University of Science and Technology of China, Hefei, China
| | - Chao-Nan Qian
- Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- *Correspondence: Chao-Nan Qian ;
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Moran P, Cullinan J. Is mammography screening an effective public health intervention? Evidence from a natural experiment. Soc Sci Med 2022; 305:115073. [PMID: 35660698 DOI: 10.1016/j.socscimed.2022.115073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/09/2022] [Accepted: 05/23/2022] [Indexed: 11/17/2022]
Abstract
Population-based breast screening programmes aim to improve clinical outcomes, alleviate health inequalities, and reduce healthcare costs. However, while screening can bring about immediate changes in mode of presentation and stage at diagnosis of breast cancer cases, the benefits and harms of these programmes can only be observed at a population level, and only over a long enough timeframe for the cascade of events triggered by screening to culminate in disease-specific mortality reductions. In this paper we exploit a natural experiment resulting from the phased geographic rollout of a national mammography screening programme to examine the impact of screening on breast cancer outcomes from both a patient cohort and a population perspective. Using data on 33,722 breast cancer cases over the period 1994-2011, we employ a difference-in-differences research design using ten-year follow-up data for cases diagnosed before and after the introduction of the programme in screened and unscreened regions. We conclude that although the programme produced the intended intermediate effects on breast cancer presentation and incidence, these failed to translate into significant decreases in overall population-level mortality, though screening may have helped to reduce socioeconomic disparities in late stage breast cancer incidence.
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Affiliation(s)
- Patrick Moran
- School of Medicine, Trinity College Dublin, College Green, Dublin 2, Ireland.
| | - John Cullinan
- School of Business & Economics, National University of Ireland Galway, University Road, Galway, Ireland.
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No Association Between Breast Pain and Breast Cancer. A Prospective Cohort Study of 10,830 Symptomatic Women Presenting to a Breast Cancer Diagnostic Clinic. Br J Gen Pract 2021; 72:e234-e243. [PMID: 34990395 PMCID: PMC8869188 DOI: 10.3399/bjgp.2021.0475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/10/2021] [Indexed: 01/03/2023] Open
Abstract
Background Women with breast pain constitute upto 20% of breast clinic attendees. AIM To investigate breast cancer incidence in women presenting with breast pain and establish health economics of referring women with breast pain to secondary care. DESIGN & SETTING Prospective cohort study of all consecutive women referred to a breast diagnostic clinic over 12 months. METHODS Women were categorised by presentation into 4 distinct clinical groups and cancer incidence investigated. RESULTS Of 10 830 women, 1972 (18%) were referred with breast pain, 6708 (62%) with lumps, 480 (4%) with nipple symptoms,1670 (15%) with 'other' symptoms. Mammography, performed in 1112 women with breast pain, identified cancer in 8 (0.7%). In 1972 women with breast pain, breast cancer incidence was 0.4% compared with ~5% in each of the three other clinical groups. Using 'breast lump' as reference, odds ratio (OR) of women referred with breast pain having breast cancer was 0.05 (95% confidence interval 0.02-0.09; P<0.001). Compared to reassurance in primary-care, referral was more costly (net cost £262) without additional health benefits (net Quality Adjusted Life Year (QALY) loss -0.012) Greatest impact on the incremental cost effectiveness ratio (ICER) was when QALY loss due to referral associated anxiety was excluded. Primary-care reassurance no longer dominated, but the ICER remained greater (£45,528/QALY) than typical UK National Health Service cost-effectiveness thresholds. CONCLUSIONS This study shows that referring women with breast pain to a breast diagnostic clinic is an inefficient use of limited resources. Alternative management pathways could improve capacity and reduce financial burden.
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Tari DU, Morelli L, Guida A, Pinto F. Male Breast Cancer Review. A Rare Case of Pure DCIS: Imaging Protocol, Radiomics and Management. Diagnostics (Basel) 2021; 11:diagnostics11122199. [PMID: 34943439 PMCID: PMC8700459 DOI: 10.3390/diagnostics11122199] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/17/2021] [Accepted: 11/21/2021] [Indexed: 12/12/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) of male breast is a rare lesion, often associated with invasive carcinoma. When the in situ component is present in pure form, histological grade is usually low or intermediate. Imaging is difficult as gynaecomastia is often present and can mask underlying findings. We report a rare case of pure high-grade DCIS in a young male patient, with associated intraductal papilloma and atypical ductal hyperplasia. Digital breast tomosynthesis (DBT) showed an area of architectural distortion at the union of outer quadrants of the left breast without gynaecomastia. Triple assessment suggested performing a nipple-sparing mastectomy, which revealed the presence of a focal area of high-grade DCIS of 2 mm. DCIS, even of high grade, is difficult to detect with mammography and even more rare, especially when associated with other proliferative lesions. DBT with 2D synthetic reconstruction is useful as the imaging step of a triple assessment and it should be performed in both symptomatic and asymptomatic high-risk men to differentiate between malignant and benign lesions. We propose a diagnostic model to early detect breast cancer in men, optimizing resources according to efficiency, effectiveness and economy, and look forward to radiomics as a powerful tool to help radiologists.
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Affiliation(s)
- Daniele Ugo Tari
- Department of Diagnostic Senology, District 12, Palazzo della Salute, Caserta LHA, 81100 Caserta, Italy
- Correspondence: ; Tel.: +39-3493659922
| | - Luigi Morelli
- Department of Pathological Anatomy A. di Tuoro, Caserta LHA, 81031 Aversa, Italy;
| | - Antonella Guida
- Head Office, District 12, Palazzo della Salute, Caserta LHA, 81100 Caserta, Italy;
| | - Fabio Pinto
- Department of Radiology, A. Guerriero Hospital, Caserta LHA, 81025 Marcianise, Italy;
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Geuzinge HA, Obdeijn IM, Rutgers EJT, Saadatmand S, Mann RM, Oosterwijk JC, Tollenaar RAEM, de Roy van Zuidewijn DBW, Lobbes MBI, van 't Riet M, Hooning MJ, Ausems MGEM, Loo CE, Wesseling J, Luiten EJT, Zonderland HM, Verhoef C, Heijnsdijk EAM, Tilanus-Linthorst MMA, de Koning HJ. Cost-effectiveness of Breast Cancer Screening With Magnetic Resonance Imaging for Women at Familial Risk. JAMA Oncol 2021; 6:1381-1389. [PMID: 32729887 DOI: 10.1001/jamaoncol.2020.2922] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance For women with a 20% or more familial risk of breast cancer without a known BRCA1/2 (BRCA1, OMIM 113705; and BRCA2, OMIM 114480) or TP53 (OMIM 151623) variant, screening guidelines vary substantially, and cost-effectiveness analyses are scarce. Objective To assess the cost-effectiveness of magnetic resonance imaging (MRI) screening strategies for women with a 20% or more familial risk for breast cancer without a known BRCA1/2 or TP53 variant. Design, Setting, and Participants In this economic evaluation, conducted from February 1, 2019, to May 25, 2020, microsimulation modeling was used to estimate costs and effectiveness on a lifetime horizon from age 25 years until death of MRI screening among a cohort of 10 million Dutch women with a 20% or more familial risk for breast cancer without a known BRCA1/2 or TP53 variant. A Dutch screening setting was modeled. Most data were obtained from the randomized Familial MRI Screening (FaMRIsc) trial, which included Dutch women aged 30 to 55 years. A health care payer perspective was applied. Interventions Several screening protocols with varying ages and intervals including those of the randomized FaMRIsc trial, consisting of the mammography (Mx) protocol (annual mammography and clinical breast examination) and the MRI protocol (annual MRI and clinical breast examination plus biennial mammography). Main Outcomes and Measures Costs, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated and discounted by 3%. A threshold of €22 000 (US $24 795.87) per QALY was applied. Results This economic evaluation modeling study estimated that, on a lifetime horizon per 1000 women with the Mx protocol of the FaMRIsc trial, 346 breast cancers would be detected, and 49 women were estimated to die from breast cancer, resulting in 22 885 QALYs and total costs of €7 084 767 (US $7 985 134.61). The MRI protocol resulted in 79 additional QALYs and additional €2 657 266 (US $2 994 964.65). Magnetic resonance imaging performed only every 18 months between the ages of 35 and 60 years followed by the national screening program was considered optimal, with an ICER of €21 380 (US $24 097.08) compared with the previous nondominated strategy in the ranking, when applying the National Institute for Health and Care Excellence threshold. Annual screening alternating MRI and mammography between the ages of 35 and 60 years, followed by the national screening program, gave similar outcomes. Higher thresholds would favor annual MRI screening. The ICER was most sensitive to the unit cost of MRI and the utility value for ductal carcinoma in situ and localized breast cancer. Conclusions and Relevance This study suggests that MRI screening every 18 months between the ages of 35 and 60 years for women with a family history of breast cancer is cost-effective within the National Institute for Health and Care Excellence threshold for all densities. Higher thresholds would favor annual MRI screening. These outcomes support a change of current screening guidelines for this specific risk group and support MRI screening.
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Affiliation(s)
- H Amarens Geuzinge
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Inge-Marie Obdeijn
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Emiel J T Rutgers
- Department of Surgery, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Sepideh Saadatmand
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ritse M Mann
- Department of Radiology and Nuclear Medicine, Radboud University Hospital, Nijmegen, the Netherlands.,Department of Radiology and Nuclear Medicine, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Jan C Oosterwijk
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, the Netherlands.,Department of Genetics, Groningen University, University Medical Centre Groningen, Groningen, the Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Marc B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Maartje J Hooning
- Department of Medical Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Claudette E Loo
- Department of Radiology and Nuclear Medicine, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Jelle Wesseling
- Department of Pathology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | - Harmien M Zonderland
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Cees Verhoef
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Eveline A M Heijnsdijk
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Harry J de Koning
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
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Saxby K, Nickson C, Mann GB, Park A, Bromley H, Velentzis L, Procopio P, Canfell K, Petrie D. Moving beyond the stage: how characteristics at diagnosis dictate treatment and treatment-related quality of life year losses for women with early stage invasive breast cancer. Expert Rev Pharmacoecon Outcomes Res 2020; 21:847-857. [PMID: 33253057 DOI: 10.1080/14737167.2021.1857735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background:Although evaluations of breast cancer screening programs frequently estimate quality-adjusted life-year (QALY) losses by stage, other breast cancer characteristics influence treatment and vary by mode of detection - i.e. whether the cancer is detected through screening (screen-detected), between screening rounds (interval-detected) or outside screening (community-detected). Here, we estimate the association between early-stage invasive breast cancer (ESIBC) characteristics and treatment-related QALY losses.Methods:Using clinicopathological and treatment information from 675 women managed for ESIBC, we estimated the average five-year treatment-related QALY loss by detection group. We then used regression analysis to estimate the extent to which known cancer characteristics and the detection mode, are associated with treatment and treatment-related QALY losses.Results:Community-detected cancers had the largest QALY loss (0.76 QALYs [95% CI 0.73;0.80]), followed by interval-detected cancers (0.75 QALYs [95% CI 0.68;0.82]) and screen-detected cancers (0.69 QALYs [95%CI 0.67;0.71]). Adverse prognostic factors more common in community-detected and interval-detected breast cancers (large tumours, lymph node involvement, high grade) were largely associated with QALY losses from mastectomies and chemotherapy. Receptor-positive subtypes, more common in screen-detected cancers, were associated with QALY losses related to endocrine therapy.Conclusions:The associations between ESIBC characteristics and treatment-related QALY losses should be considered when evaluating breast cancer screening and treatment strategies.
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Affiliation(s)
- Karinna Saxby
- Centre for Health Economics, Monash Business School, Monash University, Caulfield East, VIC, Australia
| | - Carolyn Nickson
- Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia.,Cancer Research Division, Cancer Council NSW, Kings Cross, NSW, Australia.,Sydney School of Public Health, Fisher Rd, The University of Sydney, Camperdown,NSW, Australia
| | - G Bruce Mann
- The Breast Service, Royal Melbourne and Royal Women's Hospital, Parkville, VIC, Australia
| | - Allan Park
- The Breast Service, Royal Melbourne and Royal Women's Hospital, Parkville, VIC, Australia
| | - Hannah Bromley
- Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia.,Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Louiza Velentzis
- Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia.,Cancer Research Division, Cancer Council NSW, Kings Cross, NSW, Australia.,Sydney School of Public Health, Fisher Rd, The University of Sydney, Camperdown,NSW, Australia
| | - Pietro Procopio
- Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia.,Cancer Research Division, Cancer Council NSW, Kings Cross, NSW, Australia.,Sydney School of Public Health, Fisher Rd, The University of Sydney, Camperdown,NSW, Australia
| | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Kings Cross, NSW, Australia
| | - Dennis Petrie
- Centre for Health Economics, Monash Business School, Monash University, Caulfield East, VIC, Australia
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10
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Cost-effectiveness of long-term clinical management of BRCA pathogenic variant carriers. Genet Med 2020; 22:831-839. [DOI: 10.1038/s41436-020-0751-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 01/13/2020] [Indexed: 11/08/2022] Open
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11
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Bromley HL, Mann GB, Petrie D, Nickson C, Rea D, Roberts TE. Valuing preferences for treating screen detected ductal carcinoma in situ. Eur J Cancer 2019; 123:130-137. [PMID: 31689678 DOI: 10.1016/j.ejca.2019.09.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Mammographic screening reduces breast cancer mortality but may lead to the overdiagnosis and overtreatment of low-risk breast cancers. Conservative management may reduce the potential harm of overtreatment, yet little is known about the impact upon quality of life. OBJECTIVES To quantify women's preferences for managing low-risk screen detected ductal carcinoma in situ (DCIS), including the acceptability of active monitoring as an alternative treatment. METHODS Utilities (cardinal measures of quality of life) were elicited from 172 women using visual analogue scales (VASs), standard gambles, and the Euro-Qol-5D-5L questionnaire for seven health states describing treatments for low-risk DCIS. Sociodemographics and breast cancer history were examined as predictors of utility. RESULTS Both patients and non-patients valued active monitoring more favourably on average than conventional treatment. Utilities were lowest for DCIS treated with mastectomy (VAS: 0.454) or breast conserving surgery (BCS) with adjuvant radiotherapy (VAS: 0.575). The utility of active monitoring was comparable to BCS alone but was rated more favourably as progression risk was reduced from 40% to 10%. Disutility for active monitoring was likely driven by anxiety around progression, whereas conventional management impacted other dimensions of quality of life. The heterogeneity between individual preferences could not be explained by sociodemographic variables, suggesting that the factors influencing women's preferences are complex. CONCLUSIONS Active monitoring of low-risk DCIS is likely to be an acceptable alternative for reducing the impact of overdiagnosis and overtreatment in terms of quality of life. Further research is required to determine subgroups more likely to opt for conservative management.
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Affiliation(s)
- Hannah L Bromley
- Health Economics Unit, University of Birmingham, Edgbaston, West Midlands, UK; Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia
| | - G Bruce Mann
- Department of Surgery, University of Melbourne, Parkville, Australia
| | - Dennis Petrie
- Centre for Health Economics, Monash Business School, Monash University, Australia
| | - Carolyn Nickson
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia; Cancer Research Division, Cancer Council NSW, Australia
| | - Daniel Rea
- Cancer Research UK Clinical Trials Unit, University Hospital of Birmingham, West Midlands, UK
| | - Tracy E Roberts
- Health Economics Unit, University of Birmingham, Edgbaston, West Midlands, UK.
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