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Evans DG, Astley S, Stavrinos P, Harkness E, Donnelly LS, Dawe S, Jacob I, Harvie M, Cuzick J, Brentnall A, Wilson M, Harrison F, Payne K, Howell A. Improvement in risk prediction, early detection and prevention of breast cancer in the NHS Breast Screening Programme and family history clinics: a dual cohort study. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04110] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BackgroundIn the UK, women are invited for 3-yearly mammography screening, through the NHS Breast Screening Programme (NHSBSP), from the ages of 47–50 years to the ages of 69–73 years. Women with family histories of breast cancer can, from the age of 40 years, obtain enhanced surveillance and, in exceptionally high-risk cases, magnetic resonance imaging. However, no NHSBSP risk assessment is undertaken. Risk prediction models are able to categorise women by risk using known risk factors, although accurate individual risk prediction remains elusive. The identification of mammographic breast density (MD) and common genetic risk variants [single nucleotide polymorphisms (SNPs)] has presaged the improved precision of risk models.ObjectivesTo (1) identify the best performing model to assess breast cancer risk in family history clinic (FHC) and population settings; (2) use information from MD/SNPs to improve risk prediction; (3) assess the acceptability and feasibility of offering risk assessment in the NHSBSP; and (4) identify the incremental costs and benefits of risk stratified screening in a preliminary cost-effectiveness analysis.DesignTwo cohort studies assessing breast cancer incidence.SettingHigh-risk FHC and the NHSBSP Greater Manchester, UK.ParticipantsA total of 10,000 women aged 20–79 years [Family History Risk Study (FH-Risk); UK Clinical Research Network identification number (UKCRN-ID) 8611] and 53,000 women from the NHSBSP [aged 46–73 years; Predicting the Risk of Cancer At Screening (PROCAS) study; UKCRN-ID 8080].InterventionsQuestionnaires collected standard risk information, and mammograms were assessed for breast density by a number of techniques. All FH-Risk and 10,000 PROCAS participants participated in deoxyribonucleic acid (DNA) studies. The risk prediction models Manual method, Tyrer–Cuzick (TC), BOADICEA (Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm) and Gail were used to assess risk, with modelling based on MD and SNPs. A preliminary model-based cost-effectiveness analysis of risk stratified screening was conducted.Main outcome measuresBreast cancer incidence.Data sourcesThe NHSBSP; cancer registration.ResultsA total of 446 women developed incident breast cancers in FH-Risk in 97,958 years of follow-up. All risk models accurately stratified women into risk categories. TC had better risk precision than Gail, and BOADICEA accurately predicted risk in the 6268 single probands. The Manual model was also accurate in the whole cohort. In PROCAS, TC had better risk precision than Gail [area under the curve (AUC) 0.58 vs. 0.54], identifying 547 prospective breast cancers. The addition of SNPs in the FH-Risk case–control study improved risk precision but was not useful inBRCA1(breast cancer 1 gene) families. Risk modelling of SNPs in PROCAS showed an incremental improvement from using SNP18 used in PROCAS to SNP67. MD measured by visual assessment score provided better risk stratification than automatic measures, despite wide intra- and inter-reader variability. Using a MD-adjusted TC model in PROCAS improved risk stratification (AUC = 0.6) and identified significantly higher rates (4.7 per 10,000 vs. 1.3 per 10,000;p < 0.001) of high-stage cancers in women with above-average breast cancer risks. It is not possible to provide estimates of the incremental costs and benefits of risk stratified screening because of lack of data inputs for key parameters in the model-based cost-effectiveness analysis.ConclusionsRisk precision can be improved by using DNA and MD, and can potentially be used to stratify NHSBSP screening. It may also identify those at greater risk of high-stage cancers for enhanced screening. The cost-effectiveness of risk stratified screening is currently associated with extensive uncertainty. Additional research is needed to identify data needed for key inputs into model-based cost-effectiveness analyses to identify the impact on health-care resource use and patient benefits.Future workA pilot of real-time NHSBSP risk prediction to identify women for chemoprevention and enhanced screening is required.FundingThe National Institute for Health Research Programme Grants for Applied Research programme. The DNA saliva collection for SNP analysis for PROCAS was funded by the Genesis Breast Cancer Prevention Appeal.
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Affiliation(s)
- D Gareth Evans
- Department of Genomic Medicine, Institute of Human Development, Manchester Academic Health Science Centre (MAHSC), Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Susan Astley
- Institute of Population Health, Centre for Imaging Sciences, University of Manchester, Manchester, UK
| | - Paula Stavrinos
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Elaine Harkness
- Institute of Population Health, Centre for Imaging Sciences, University of Manchester, Manchester, UK
| | - Louise S Donnelly
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Sarah Dawe
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Ian Jacob
- Department of Health Economics, University of Manchester, Manchester, UK
| | - Michelle Harvie
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | - Jack Cuzick
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Adam Brentnall
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Mary Wilson
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
| | | | - Katherine Payne
- Department of Health Economics, University of Manchester, Manchester, UK
| | - Anthony Howell
- Institute of Population Health, Centre for Imaging Sciences, University of Manchester, Manchester, UK
- The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester, Manchester, UK
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Pharoah PDP, Sewell B, Fitzsimmons D, Bennett HS, Pashayan N. Cost effectiveness of the NHS breast screening programme: life table model. BMJ 2013; 346:f2618. [PMID: 23661112 PMCID: PMC3649817 DOI: 10.1136/bmj.f2618] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the overall cost effectiveness of the NHS breast screening programme, based on findings of the Independent UK Panel on Breast Cancer Screening and taking into account the uncertainty of associated estimates of benefits, harms, and costs. DESIGN A life table model comparing data from two cohorts. SETTING United Kingdom's health service. PARTICIPANTS AND INTERVENTIONS 364,500 women aged 50 years-the population of 50 year old women in England and Wales who would be eligible for screening-were followed up for 35 years without screening, compared with a similar cohort who had regular mammographic screening between ages 50 and 70 years and were then followed for another 15 years. MAIN OUTCOME MEASURES Between the cohorts, we compared the number of breast cancer diagnoses, number of deaths from breast cancer, number of deaths from other causes, person years of survival adjusted for health quality, and person years of survival with breast cancer. We also calculated the costs of treating primary and end stage breast cancer, and the costs of screening. Probabilistic sensitivity analysis explored the effect of uncertainty in key input parameters on the model outputs. RESULTS Under the base case scenario (using input parameters derived from the Independent Panel Review), there were 1521 fewer deaths from breast cancer and 2722 overdiagnosed breast cancers. Discounting future costs and benefits at a rate of 3.5% resulted in an additional 6907 person years of survival in the screened cohort, at a cost of 40,946 additional years of survival after a diagnosis of breast cancer. Screening was associated with 2040 additional quality adjusted life years (QALYs) at an additional cost of £42.5m (€49.8m; $64.7m) in total or £20,800 per QALY gained. The gain in person time survival over 35 years was 9.2 days per person and 2.7 quality adjusted days per person screened. Probabilistic sensitivity analysis showed that this incremental cost effectiveness ratio varied widely across a range of plausible scenarios. Screening was cost effective at a threshold of £20,000 per QALY gained in 2260 (45%) scenarios, but in 588 (12%) scenarios, screening was associated with a reduction in QALYs. CONCLUSION The NHS breast screening programme is only moderately likely to be cost effective at a standard threshold. However, there is substantial uncertainty in the model parameter estimates, and further primary research will be needed for cost effectiveness studies to provide definitive data to inform policy.
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Affiliation(s)
- Paul D P Pharoah
- Departments of Oncology and Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
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Shaw CM, Flanagan FL, Fenlon HM, McNicholas MM. Consensus Review of Discordant Findings Maximizes Cancer Detection Rate in Double-Reader Screening Mammography: Irish National Breast Screening Program Experience. Radiology 2009; 250:354-62. [DOI: 10.1148/radiol.2502080224] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Taylor PM. A review of research into the development of radiologic expertise: implications for computer-based training. Acad Radiol 2007; 14:1252-63. [PMID: 17889342 DOI: 10.1016/j.acra.2007.06.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2007] [Revised: 06/08/2007] [Accepted: 06/08/2007] [Indexed: 11/25/2022]
Abstract
RATIONALE AND OBJECTIVES Studies of radiologic error reveal high levels of variation between radiologists. Although it is known that experts outperform novices, we have only limited knowledge about radiologic expertise and how it is acquired. MATERIALS AND METHODS This review identifies three areas of research: studies of the impact of experience and related factors on the accuracy of decision-making; studies of the organization of expert knowledge; and studies of radiologists' perceptual processes. RESULTS AND CONCLUSION Interpreting evidence from these three paradigms in the light of recent research into perceptual learning and studies of the visual pathway has a number of conclusions for the training of radiologists, particularly for the design of computer-based learning programs that are able to illustrate the similarities and differences between diagnoses, to give access to large numbers of cases and to help identify weaknesses in the way trainees build up a global representation from fixated regions.
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Affiliation(s)
- Paul M Taylor
- University College London, Archway Campus, Highgate Hill, London N19 5LW, United Kingdom.
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Griebsch I, Brown J, Boggis C, Dixon A, Dixon M, Easton D, Eeles R, Evans DG, Gilbert FJ, Hawnaur J, Kessar P, Lakhani SR, Moss SM, Nerurkar A, Padhani AR, Pointon LJ, Potterton J, Thompson D, Turnbull LW, Walker LG, Warren R, Leach MO. Cost-effectiveness of screening with contrast enhanced magnetic resonance imaging vs X-ray mammography of women at a high familial risk of breast cancer. Br J Cancer 2006; 95:801-10. [PMID: 17016484 PMCID: PMC2360541 DOI: 10.1038/sj.bjc.6603356] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Contrast enhanced magnetic resonance imaging (CE MRI) is the most sensitive tool for screening women who are at high familial risk of breast cancer. Our aim in this study was to assess the cost-effectiveness of X-ray mammography (XRM), CE MRI or both strategies combined. In total, 649 women were enrolled in the MARIBS study and screened with both CE MRI and mammography resulting in 1881 screens and 1–7 individual annual screening events. Women aged 35–49 years at high risk of breast cancer, either because they have a strong family history of breast cancer or are tested carriers of a BRCA1, BRCA2 or TP53 mutation or are at a 50% risk of having inherited such a mutation, were recruited from 22 centres and offered annual MRI and XRM for between 2 and 7 years. Information on the number and type of further investigations was collected and specifically calculated unit costs were used to calculate the incremental cost per cancer detected. The numbers of cancer detected was 13 for mammography, 27 for CE MRI and 33 for mammography and CE MRI combined. In the subgroup of BRCA1 (BRCA2) mutation carriers or of women having a first degree relative with a mutation in BRCA1 (BRCA2) corresponding numbers were 3 (6), 12 (7) and 12 (11), respectively. For all women, the incremental cost per cancer detected with CE MRI and mammography combined was £28 284 compared to mammography. When only BRCA1 or the BRCA2 groups were considered, this cost would be reduced to £11 731 (CE MRI vs mammography) and £15 302 (CE MRI and mammography vs mammography). Results were most sensitive to the unit cost estimate for a CE MRI screening test. Contrast-enhanced MRI might be a cost-effective screening modality for women at high risk, particularly for the BRCA1 and BRCA2 subgroups. Further work is needed to assess the impact of screening on mortality and health-related quality of life.
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Affiliation(s)
- I Griebsch
- MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, Bristol, UK
| | - J Brown
- MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, Bristol, UK
| | - C Boggis
- Nightingale Centre, Withington Hospital, Manchester, UK
| | - A Dixon
- Addenbrooke's Hospital, Cambridge, UK
| | - M Dixon
- Western General Hospital, Edinburgh, UK
| | - D Easton
- CRC Genetic Epidemiology Unit, Cambridge, UK
| | - R Eeles
- MARIBS Study Office, Section Magnetic Resonance, The Institute of Cancer Research & the Royal Marsden NHS Trust, Downs Road, Sutton, Sussey SM2 5PT, UK
| | - D G Evans
- Regional Genetics Service, Manchester, UK
| | - F J Gilbert
- Department of Radiology, University of Aberdeen, Aberdeen, UK
| | - J Hawnaur
- Department of Clinical Radiology, Manchester Royal Infirmary, Manchester, UK
| | - P Kessar
- MARIBS Study Office, Section Magnetic Resonance, The Institute of Cancer Research & the Royal Marsden NHS Trust, Downs Road, Sutton, Sussey SM2 5PT, UK
| | - S R Lakhani
- Discipline of Molecular & Cellular Pathology, School of Medicine, University of Queensland Mayne Medical School, Australia
| | - S M Moss
- MARIBS Study Office, Section Magnetic Resonance, The Institute of Cancer Research & the Royal Marsden NHS Trust, Downs Road, Sutton, Sussey SM2 5PT, UK
| | | | - A R Padhani
- The Paul Strickland Scanner Centre, Mount Vernon Hospital, Middlesex, UK
| | - L J Pointon
- MARIBS Study Office, Section Magnetic Resonance, The Institute of Cancer Research & the Royal Marsden NHS Trust, Downs Road, Sutton, Sussey SM2 5PT, UK
| | - J Potterton
- MRI Unit, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - D Thompson
- CRC Genetic Epidemiology Unit, Cambridge, UK
| | - L W Turnbull
- Centre for Magnetic Resonance Investigations, Hull Royal Infirmary, Hull, UK
| | - L G Walker
- Institute of Rehabilitation, University of Hull, Hull, UK
| | - R Warren
- Addenbrooke's Hospital, Cambridge, UK
| | - M O Leach
- MARIBS Study Office, Section Magnetic Resonance, The Institute of Cancer Research & the Royal Marsden NHS Trust, Downs Road, Sutton, Sussey SM2 5PT, UK
- E-mail:
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Holt JJ. Evaluating Radiological Technologist's Ability to Detect Abnormalities in Film-Screen Mammographic Images: A Decision Analysis Pilot Project. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/s0820-5930(09)60133-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Duijm LEM, Groenewoud JH, Hendriks JHCL, de Koning HJ. Independent Double Reading of Screening Mammograms in the Netherlands: Effect of Arbitration Following Reader Disagreements. Radiology 2004; 231:564-70. [PMID: 15044742 DOI: 10.1148/radiol.2312030665] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively determine the value of arbitration by a panel of radiologists when two radiologists performing independent readings of screening mammograms do not reach a consensus about referral. MATERIALS AND METHODS The study population consisted of women who participated in the Dutch Nationwide Breast Cancer Screening Program, in which biennial screening is offered to women aged 50-75 years. An arbitration panel of three radiologists assessed those screening mammograms for which two screening radiologists did not reach a consensus about referral necessity. Women were referred for further analysis if at least one arbitration panel radiologist considered referral to be necessary. RESULTS The two screening radiologists agreed on the recommendation for referral of 498 (0.8%) of 65,779 screened women and on the recommendation for no referral of 64,949 (98.7%) women. They initially disagreed about the referral in 332 (0.5%) cases. After a mutual consultation, disagreement persisted regarding 183 (0.3%) mammograms. The arbitration panel referred 89 of these cases for further analysis, which revealed cancer in 20 (22%) cases. In three (3%) of the 94 cases that were not referred by the panel, breast cancer was detected at the site of previously discrepant mammographic findings seen at subsequent screening performed 2 years later. If all 183 discrepant cases had been referred, the referral rate would have increased from 0.8% to 0.9% at subsequent (incident) screenings and from 1.5% to 1.7% at initial screenings. In addition, at subsequent screenings, the number of cancers detected per 1,000 women screened would have increased from 4.4 to 4.5. CONCLUSION Mammograms with discrepant findings constitute a very important subset of screening mammograms. All lesions that are subsequently proved to be malignant may not be detected with panel arbitration.
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Affiliation(s)
- Lucien E M Duijm
- Department of Radiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands.
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Dinnes J, Moss S, Melia J, Blanks R, Song F, Kleijnen J. Effectiveness and cost-effectiveness of double reading of mammograms in breast cancer screening: findings of a systematic review. Breast 2004; 10:455-63. [PMID: 14965624 DOI: 10.1054/brst.2001.0350] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2001] [Revised: 05/07/2001] [Accepted: 05/16/2001] [Indexed: 11/18/2022] Open
Abstract
There is a lack of direct evidence on the effectiveness of double reading of breast screening mammograms within the context of national screening programmes even though about half of the countries that use mammography screening have implemented double reading. A systematic review was conducted to compare double reading with single reading of mammograms for screening accuracy, patient outcomes and costs. We searched an extensive range of electronic databases, bibliographies of studies were scanned and experts were contacted. Data extraction and quality assessment was undertaken independently by two reviewers. Estimates of the diagnostic accuracy were calculated for those studies with follow-up to identify interval cancers. Only 10 cohort studies met the inclusion criteria with reported extractable data on the effectiveness of double compared to single reading. The mix of methodologies meant that few conclusions could be drawn about the effect of double reading independent of number of views, or effects on size and type of tumours detected. Overall, double reading increases the cancer detection rate by 3-11 per 10,000 women screened and has a double impact on recall rates depending on the recall policy used. The benefit could be mainly in the detection of small cancers, and could be greatest where two readers have different strengths and weaknesses, or where readers are less experienced. Double reading can improve accuracy as compared with single reading. In particular, double reading by consensus or arbitration achieves an increase in cancer detection rate together with a reduction in the rate of women recalled for assessment. Further research should quantify the relative benefit from double reading according to recall policy and number of mammographic views, and estimate the impact on patient outcome.
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Affiliation(s)
- J Dinnes
- NHS Centre for Reviews and Dissemination, University of York, UK.
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Mitton C, Jarrell JF. Economic evaluation in obstetrics and gynaecology: principles and practice. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2003; 25:219-23. [PMID: 12610674 DOI: 10.1016/s1701-2163(16)30109-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Greater attention in health care over the last 2 decades has been placed on determining how best to spend the resources available. Economic evaluation is a commonly used tool to compare health-care services and treatments on the basis of costs and benefits. However, the principles on which economic evaluations are based are not well understood, and guidelines for conducting such evaluations in practice are often not followed. This paper describes the overarching principle of opportunity cost, and highlights the implication that decision-making in health care should necessarily be based on both costs and benefits. Two notions of efficiency, technical and allocative, are also presented, and the important point is made that the specific type of economic evaluation chosen must be based not on the unit of benefit in the given study, as is commonly done, but rather on the type of efficiency being addressed. The 3 primary types of economic evaluation are outlined, and a common pitfall in economic evaluation, the incremental cost-effectiveness ratio, is critiqued. Finally, a number of methodological considerations when conducting economic evaluations in practice are presented.
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Affiliation(s)
- Craig Mitton
- Centre for Health and Policy Studies, University of Calgary, Calgary, AB, Canada
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Affiliation(s)
- Cam Donaldson
- School of Population and Health Sciences and Business School, University of Newcastle upon Tyne, Newcastle upon Tyne NE1 7RU.
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