Cost-effectiveness of detecting breast cancer in lower socioeconomic status African American and Hispanic women through mobile mammography services

Economic Evaluations of Interventions Addressing Inequalities in Cancer Care: A Systematic Review

OBJECTIVES

Although substantial evidence exists on the costs and benefits of cancer care and screening programs for the general population, economic evidence of interventions addressing inequalities is less well known. This systematic review summarized economic evaluations of interventions addressing inequalities in cancer screening and care to inform decision makers on the value for money of such interventions.

METHODS

Embase, MEDLINE, Cochrane Library, EconLit, and Scopus databases were searched for studies published from database inception to October 27, 2023. Studies were eligible for inclusion if they were economic evaluations of interventions to improve or address inequalities in cancer care among disadvantaged population groups. Study characteristics and cost-effectiveness results (US dollars 2023) were summarized. Study quality was assessed by 2 authors using the Drummond checklist.

RESULTS

The searches yielded 2937 records, with 30 meeting the eligibility criteria for data extraction. In most of the studies (n = 27, 90%), interventions were considered cost-effective in addressing inequalities in cancer care and screening among disadvantaged populations. Notably, 60% of the studies were rated as high quality, 33.3% as good, and 6.7% as fair quality.

CONCLUSIONS

This systematic review identified cost-effective strategies addressing inequalities in cancer screening and care that have the potential to be replicated in other locations. The interventions were mainly focused on screening programs, and few addressed equity gaps around risk reduction and diagnostic and treatment outcomes. This underscores the need for targeted approaches to address inequalities in under-researched priority population groups along the cancer care continuum.

Reflections of Homeless Women and Women with Mental Health Challenges on Breast and Cervical Cancer Screening Decisions: Power, Trust, and Communication with Care Providers

This study conducted in Toronto, Canada, explored the perceptions of women living in homeless shelters and women with severe mental health challenges about the factors influencing their decision-making processes regarding breast and cervical cancer screening. Twenty-six in-depth qualitative interviews were conducted. The objectives of this research were (i) to provide new insights about women's decision-making processes, (ii) to describe the barriers to and facilitators for breast and cervical cancer screening, and (iii) to offer recommendations for future outreach, education, and screening initiatives developed specifically for under/never-screened marginalized women living in urban centers. This exploratory study utilized thematic analysis to broaden our understanding about women's decision-making processes. A constructed ontology was used in an attempt to understand and describe participants' constructed realities. The epistemological framework was subjective and reflected co-created knowledge. The approach was hegemonic, values-based, and context-specific. The aim of the analysis was to focus on meanings and actions with a broader view to identify the interplay between participants' narratives and social structures, medical praxis, and policy implications. Results from 26 qualitative interviews conducted in 2013-2014 provided insights on both positive and negative prior cancer screening experiences, the role of power and trust in women's decision-making, and areas for improvement in health care provider/patient interactions. Outcomes of this investigation contribute to the future development of appropriately designed intervention programs for marginalized women, as well as for sensitivity training for health care providers. Tailored and effective health promotion strategies leading to life-long cancer screening behaviors among marginalized women may improve clinical outcomes, decrease treatment costs, and save lives.

Mobile Versus Fixed Facility: Latinas' Attitudes and Preferences for Obtaining a Mammogram

PURPOSE

Mobile mammographic services have been proposed as a way to reduce Latinas' disproportionate late-stage presentation compared with white women by increasing their access to mammography. The aims of this study were to assess why Latinas may not use mobile mammographic services and to explore their preferences after using these services.

METHODS

Using a mixed-methods approach, a secondary analysis was conducted of baseline survey data (n = 538) from a randomized controlled trial to improve screening mammography rates among Latinas in Washington. Descriptive statistics and bivariate regression were used to characterize mammography location preferences and to test for associations with sociodemographic indices, health care access, and perceived breast cancer risk and beliefs. On the basis of these findings, a qualitative study (n = 18) was used to explore changes in perceptions after using mobile mammographic services.

RESULTS

More Latinas preferred obtaining a mammogram at a fixed facility (52.3% [n = 276]) compared with having no preference (46.3% [n = 249]) and preferring mobile mammographic services (1.7% [n = 9]). Concerns about privacy and comfort (15.6% [n = 84]) and about general quality (10.6% [n = 57]) were common reasons for preferring a fixed facility. Those with no history of mammography preferred a fixed facility (P < .05). In the qualitative study, Latinas expressed similar initial concerns but became positive toward the mobile mammographic services after obtaining a mammogram.

CONCLUSIONS

Although most Latinas preferred obtaining a mammogram at a fixed facility, positive experiences with mobile mammography services changed their attitudes toward them. These findings highlight the need to include community education when using mobile mammographic service to increase screening mammography rates in underserved communities.

Inclusion of equity in economic analyses of public health policies: systematic review and future directions

OBJECTIVES

To assess current approaches to inclusion of equity in economic analysis of public health interventions and to recommend best approaches and future directions.

METHODS

We conducted a systematic review of studies that have used socioeconomic position (SEP) in cost-effectiveness analyses. Studies were identified using MedLine, EconLit and HEED and were evaluated based on their SEP specific inputs and methods of quantification of the health and financial inequalities.

RESULTS

Twenty-nine relevant studies were identified. The majority of studies comparing two or more interventions left interpretation of the size of the health and financial inequality differences to the reader. Newer approaches include: i) use of health inequality measures to quantify health inequalities; ii) inclusion of financial impacts, such as out-of-pocket expenditures; and iii) use of equity weights. The challenge with these approaches is presenting results that policy makers can easily interpret.

CONCLUSIONS

Using CEA techniques to generate new information about the health equity implications of alternative policy options has not been widely used, but should be considered to inform future decision making. Implications for public health: Inclusion of equity in economic analysis would facilitate a more nuanced comparison of interventions in relation to efficiency, equity and financial impact.

Contribution and performance of mobile units in an organized mammography screening program

BACKGROUND

The aims of this study were to evaluate the contribution of mobile mammography units to participation rate and to compare their performance to fixed screening centres within the organized mammography screening program of Quebec, Canada.

METHODS

The study is based on all screening mammograms carried out in women aged 50-69 who participated in the Québec program from 2002 to 2010. Performance was measured by screening sensitivity, false-positive rate (1-specificity), positive likelihood ratio as well as abnormal call rate, detection rate, interval cancer rate, positive predictive value, and tumour characteristics. Poisson regression models with robust variance estimation were used to take into account the multi-level structure of the data. All models were adjusted for characteristics related to women.

RESULTS

During the 2002-2010 period, 2,292,592 screening mammograms were performed, of which 42,279 (1.8%) were in mobile units. In regions serviced exclusively by mobile units, the participation rate reached an average of 63.4% during the 2006-2010 period compared to 54.7% for the entire study population. Estimated sensitivity was similar to that of fixed sites (rate ratio = 0.98 [0.84-1.15]) while the false-positive rate was lower (rate ratio = 0.76 [0.57-1.02]) although this difference was of marginal statistical significance (p=0.07).

CONCLUSIONS

In this program, mobile mammography units allowed regions lacking a fixed centre to attain participation rates slightly higher than those in the rest of Quebec, without loss of sensitivity and with some gain in the false-positive rate.

Developing and testing a cost-assessment tool for cancer screening programs

BACKGROUND

Cancer screening programs require substantial resources, and economic assessments have become increasingly important in identifying the most cost-effective means of conducting these programs. Such economic assessments require detailed program cost data, but there is no standardized instrument for obtaining these data.

PURPOSE

This study was designed to develop a standardized instrument to collect cost data from cancer screening programs.

METHODS

A cost-assessment tool (CAT) was developed to collect annual cost data based on the findings from case studies at four sites funded by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The data elements collected in the CAT were specifically tailored to collect cost and resource-use information from cancer screening programs. The tool was pilot-tested at nine NBCCEDP sites, and activity-based costs were generated by assigning all cost and resource-use data to specific program activities. Data were collected from November 2004 to February 2005, and the analysis was performed from March to July 2005.

RESULTS

Overall, a majority of the sites (eight of nine) met the acceptable threshold of <5% of total cost remaining unallocated. On average, the largest cost components of the nine programs were screening and diagnostic services (44.4%); recruitment (11.4%); database management (10.9%); and patient support/case management (9.3%).

CONCLUSIONS

Findings from the CAT pilot-testing showed that NBCCEDP cancer screening programs were able to report detailed activity-based cost data. The comparability of these cost data across programs should facilitate pooled analyses that, in turn, may lead to a better understanding of the impact and cost effectiveness of the screening program.

Cost analysis of the National Breast and Cervical Cancer Early Detection Program: selected states, 2003 to 2004

BACKGROUND

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was established by the U.S. Congress in 1990. In recent years, there has been an emphasis on ascertaining the NBCCEDP's costs of delivering screening and diagnostic services to medically underserved, low-income women. The objective of this report was to address 3 economic questions: What is the cost per woman served in the program, what is the cost per woman served by program component, and what is the cost per cancer detected through the program?

METHODS

The authors developed a questionnaire to systematically collect activity-based costs on screening for breast and cervical cancer from 9 participating programs. The questionnaire was developed based on well established methods of collecting cost data for program evaluation. Data were collected from July 2003 through June 2004.

RESULTS

With in-kind contributions, the cost of screening services to women in 9 programs was estimated at $555 per woman served. Without in-kind contributions, this cost was $519. Among the program components, screening and coalitions/partnerships accounted for the highest and lowest cost per woman served, respectively. The median cost of screening a woman for breast cancer was $94, and the cost per breast cancer detected was $10,566. For cervical cancer, these costs were $56 and $13,340, respectively.

CONCLUSIONS

Costs per woman served, screened, and cancers detected are needed for programs to accurately determine the resources required to reach and screen eligible women. With limited program resources, these cost estimates can provide useful information to assist programs in planning and implementing cost-effective activities that could maximize the allocation of program resources.

Toward optimal screening strategies for older women. Costs, benefits, and harms of breast cancer screening by age, biology, and health status

CONTEXT

Optimal ages of breast cancer screening cessation remain uncertain.

OBJECTIVE

To evaluate screening policies based on age and quartiles of life expectancy (LE).

DESIGN AND POPULATION

We used a stochastic model with proxies of age-dependent biology to evaluate the incremental U.S. societal costs and benefits of biennial screening from age 50 until age 70, 79, or lifetime.

MAIN OUTCOME MEASURES

Discounted incremental costs per life years saved (LYS).

RESULTS

Lifetime screening is expensive (151,434 dollars per LYS) if women have treatment and survival comparable to clinical trials (idealized); stopping at age 79 costs 82,063 dollars per LYS. This latter result corresponds to costs associated with an LE of 9.5 years at age 79, a value expected for 75% of 79-year-olds, about 50% of 80-year-olds, and 25% of 85-year-olds. Using actual treatment and survival patterns, screening benefits are greater, and lifetime screening of all women might be considered (114,905 dollars per LYS), especially for women in the top 25% of LE for their age (50,643 dollars per LYS, life expectancy of approximately 7 years at age 90).

CONCLUSIONS

If all women receive idealized treatment, the benefits of mammography beyond age 79 are too low relative to their costs to justify continued screening. However, if treatment is not ideal, extending screening beyond age 79 could be considered, especially for women in the top 25% of life expectancy for their age.

Benefits and Costs of Interventions to Improve Breast Cancer Outcomes in African American Women

Purpose

Historically, African American women have experienced higher breast cancer mortality than white women, despite lower incidence. Our objective was to evaluate whether costs of increasing rates of screening or application of intensive treatment will be off-set by survival benefits for African American women.

Methods

We use a stochastic simulation model of the natural history of breast cancer to evaluate the incremental societal costs and benefits of status quo versus targeted biennial screening or treatment improvements among African Americans 40 years of age and older. Main outcome measures were number of mammograms, stage, all-cause mortality, and discounted costs per life year saved (LYS).

Results

At the current screening rate of 76%, there is little incremental benefit associated with further increasing screening, and the costs are high: $124,053 and $124,217 per LYS for lay health worker and patient reminder interventions, respectively, compared with the status quo. Using reminders would cost $51,537 per LYS if targeted to virtually unscreened women or $78,130 per LYS if targeted to women with a two-fold increase in baseline risk. If all patients received the most intensive treatment recommended, costs increase but deaths decrease, for a cost of $52,678 per LYS. Investments of up to $6,000 per breast cancer patient could be used to enhance treatment and still yield cost-effectiveness ratios of less than $75,000 per LYS.

Conclusion

Except in pockets of unscreened or high-risk women, further investments in interventions to increase screening are unlikely to be an efficient use of resources. Ensuring that African American women receive intensive treatment seems to be the most cost-effective approach to decreasing the disproportionate mortality experienced by this population.

Economic evaluation of breast cancer screening: A review

PURPOSE

The authors provide a review of the economic evaluation literature of breast cancer screening and identify important trends and gaps in the literature.

OVERVIEW

Healthcare resources are limited and economic evaluation plays a critical role in resource allocation, healthcare policy, and clinical decisions. Many economic evaluations of medical practice, however, are unreliable and do not use appropriate analytic techniques. Three important trends were observed. First, two economic evaluation methods are dominant. Second, a wide range of cost estimates exists across studies. Third, a lack of standardization exists across studies with regard to basic economic evaluation principles. These findings should be considered when conducting future research, analyzing economic evaluations of breast cancer screening, and developing clinical guidelines.

CLINICAL IMPLICATIONS

Concerns about cost containment in healthcare make it necessary for physicians and clinical administrators to take an active role in resource allocation decisions at the clinical level. For instance, the recent debate on the proper age to begin annual mammography screening involves both resource allocation and clinical issues. Thus, it is important for physicians and clinical administrators to be familiar with the economic evaluation literature of breast cancer screening, economic evaluation methodology, and the associated shortcomings of published estimates.