Economic analyses of breast cancer control in low- and middle-income countries: a systematic review

Breast Cancer in India: Screening, Detection, and Management

Breast cancer is the most common cancer in urban Indian women and the second most common cancer in all Indian women. The epidemiology as well as biology of this cancer seems to be different in the Indian subcontinent when compared with the West. The lack of population-based breast cancer screening programs and delay in seeking a medical consult due to financial and social reasons, including lack of awareness and fear related to a cancer diagnosis, results in delayed diagnosis.

Breast Ultrasound Volume Sweep Imaging: A New Horizon in Expanding Imaging Access for Breast Cancer Detection

OBJECTIVE

The majority of people in the world lack basic access to breast diagnostic imaging resulting in delay to diagnosis of breast cancer. In this study, we tested a volume sweep imaging (VSI) ultrasound protocol for evaluation of palpable breast lumps that can be performed by operators after minimal training without prior ultrasound experience as a means to increase accessibility to breast ultrasound.

METHODS

Medical students without prior ultrasound experience were trained for less than 2 hours on the VSI breast ultrasound protocol. Patients presenting with palpable breast lumps for standard of care ultrasound examination were scanned by a trained medical student with the VSI protocol using a Butterfly iQ handheld ultrasound probe. Video clips of the VSI scan imaging were later interpreted by an attending breast imager. Results of VSI scan interpretation were compared to the same-day standard of care ultrasound examination.

RESULTS

Medical students scanned 170 palpable lumps with the VSI protocol. There was 97% sensitivity and 100% specificity for a breast mass on VSI corresponding to 97.6% agreement with standard of care (Cohen's κ = 0.95, P < .0001). There was a detection rate of 100% for all cancer presenting as a sonographic mass. High agreement for mass characteristics between VSI and standard of care was observed, including 87% agreement on Breast Imaging-Reporting and Data System assessments (Cohen's κ = 0.82, P < .0001).

CONCLUSIONS

Breast ultrasound VSI for palpable lumps offers a promising means to increase access to diagnostic imaging in underserved areas. This approach could decrease delay to diagnosis for breast cancer, potentially improving morbidity and mortality.

Breast Cancer Screening Should Embrace Precision Medicine: Evidence by Reviewing Economic Evaluations in China

The cost-effectiveness of conventional population-based breast cancer screening strategies (e.g. mammography) has been found controversial, while evidence shows that genetic testing for early detection of pathogenic variants is cost-effective. We aimed to review the economic evaluations of breast cancer screening in China to provide an information summary for future research on this topic. We searched the literature to identify the economic evaluations that examined breast cancer screening and testing in China, supplemented by hand-searching the reference lists of the included studies. We finally included five studies satisfying our inclusion criteria. Four articles examined mammography while the rest investigated multigene testing. The existing breast cancer screening programmes were found to be cost-effective among urban Chinese women, but one study concluded that they might cause harm to women in rural areas. Contextual factors, such as data absence, urban-rural disparity, willingness-to-pay threshold, and model design, imposed barriers to cost-effectiveness analysis. Multigene testing was found to be cost-effective and has a promising population impact among all women with breast cancer in China. Future research should investigate the cost-effectiveness of screening and identifying breast cancer through precision medicine technologies, including genetic testing, genome sequencing, cascade testing, and the return of secondary findings.

Economic evaluations of mammography to screen for breast cancer in low- and middle-income countries: A systematic review

Background

Low- and middle-income countries (LMICs) have limited resources compared to high-income countries (HICs). Therefore, it is critical that LMICs implement cost-effective strategies to reduce the burden of breast cancer. This study aimed to answer the question of whether mammography is a cost-effective breast cancer screening method in LMICs.

Methods

A systematic article search was conducted through Medline, Embase, Web of Science, and Econlit. Studies were included only if they conducted a full economic evaluation and focused on mammography screening in LMICs. Two reviewers screened through the title and abstract of each article and continued with full-text selection. Data were extracted and synthesized narratively. Quality assessment for each included study was conducted using the Consensus Health Economic Criteria (CHEC) extended checklist.

Results

This review identified 21 studies economically evaluating mammography as a breast cancer screening method in LMICs. Eighteen of these studies concluded that mammography screening was a cost-effective strategy. Most studies (71%) were conducted in upper-middle-income countries (Upper MICs). The quality of the studies varied from low to good. Important factors determining cost-effectiveness are the target age group (eg, 50-59 years), the screening interval (eg, biennial or triennial), as well as any combination with other breast cancer control strategies (eg, combination with treatment strategy for breast cancer patients).

Conclusions

Mammography screening appeared to be a cost-effective strategy in LMICs, particularly in Upper MICs. More studies conducted in lower-middle-income and low-income countries are needed to better understand the cost-effectiveness of mammography screening in these regions.

Health system costs of a breast cancer early diagnosis programme in a rural district of Rwanda: a retrospective, cross-sectional economic analysis

OBJECTIVES

This study aimed to quantify the health system cost of the first 2 years of a Breast Cancer Early Detection (BCED) programme in a rural district in Rwanda. We also aimed to estimate the cost of implementing the programme in other districts with different referral pathways and identify opportunities for enhanced cost efficiency.

DESIGN

Retrospective, cross-sectional analysis using time-driven activity-based costing, based on timed patient clinical encounters, retrospective patient data and unit costs of resources abstracted from administrative and finance records.

SETTING

The BCED programme focused on timely evaluation of individuals with breast symptoms. The study evaluated the health system cost of the BCED programme at seven health centres (HCs) in Burera district and Butaro Cancer Centre of Excellence (BCCOE) at Butaro District Hospital.

OUTCOME MEASURES

Health system costs per patient visit and cost per cancer diagnosed were quantified. Total start-up and recurring operational costs were also estimated, as well as health system costs of different scale-up adaptations in other districts.

RESULTS

One-time start-up costswere US$36 917, recurring operational costswere US$67 711 and clinical costswere US$14 824 over 2 years. Clinical breast examinations (CBE) at HCs cost US$3.27/visit. At BCCOE, CBE-only visits cost US$13.47/visit, CBE/ultrasound US$14.79/visit and CBE/ultrasound/biopsy/pathology US$147.81/visit. Overall, clinical cost per breast cancer diagnosed was US$1482. Clinicalcost drivers were personnel at HCs (55%) and biopsy/pathology supplies at BCCOE (46%). In other districts, patients experience a longer breast evaluation pathway, adding about US$14.00/patient; this could be decreased if ultrasound services were decentralised.

CONCLUSION

Clinical costs associated with BCED services at HCs were modest, similar to other general outpatient services. The BCED programme's start-up and operational costs were high but could be reduced by using local trainers and virtual mentorship. In other districts, decentralising ultrasound and/or biopsies to district hospitals could reduce costs.

The Brassica Napus Extract (BNE)-Loaded PLGA Nanoparticles as an Early Necroptosis and Late Apoptosis Inducer in Human MCF-7 Breast Cancer Cells

Loading of the Brassica napus extract (BNE) on PLGA nanoparticle (BNE-PNP) and study its necroptotic activity in human MCF7-breast cancer cells. Double emulsion solvent evaporation methods were used for synthesis of BNE-PNP and DLS, SEM, and surface Zeta-potential analysis were applied for defining the physicochemical properties of BNE-PNP. The cytotoxic impact of BNE-PNP nanoparticles was analyzed by MTT assay and expression of apoptotic (P53 and Cas-3) and necrotic (TNF-α) gene markers were measured by qPCR to evaluate the BNE-PNP-induced cell death type. The stable (-36.07 mV) BNE-PNP were synthesized at 71.07 nm dimension. They significantly decrease the count of metabolically active MCF7 cells (IC₅₀: 170.94 µg/ml after 48 h). The BNE-PNP induced an early programmed necrotic (necroptosis) and late apoptotic death on the MCF7 cancer cells by up-regulating all the P53/TNF-α and Cas-3 gene expression, respectively. The BNE-PNP dose-dependently induced an early cell-selective necroptotic death. Since the necroptotic death is known as a biocompatible cellular death induction, the BNE-PNP have the potential to be used as a safe efficient anticancer compound.

High-burden Cancers in Middle-income Countries: A Review of Prevention and Early Detection Strategies Targeting At-risk Populations

Cancer incidence is rising in low- and especially middle-income countries (MIC), driven primarily by four high-burden cancers (breast, cervix, lung, colorectal). By 2030, more than two-thirds of all cancer deaths will occur in MICs. Prevention and early detection are required alongside efforts to improve access to cancer treatment. Successful strategies for decreasing cancer mortality in high-income countries are not always effective, feasible or affordable in other countries. In this review, we evaluate strategies for prevention and early detection of breast, cervix, lung, and colorectal cancers, focusing on modifiable risk factors and high-risk subpopulations. Tobacco taxation, human papilloma virus vaccination, cervical cancer screen-and-treat strategies, and efforts to reduce patient and health system-related delays in the early detection of breast and colorectal cancer represent the highest yield strategies for advancing cancer control in many MICs. An initial focus on high-risk populations is appropriate, with increasing population coverage as resources allow. These strategies can deliver significant cancer mortality gains, and serve as a foundation from which countries can develop comprehensive cancer control programs. Investment in national cancer surveillance infrastructure is needed; the absence of national cancer data to identify at-risk groups remains a barrier to the development of context-specific cancer control strategies.

Economic Evaluations of Breast Cancer Care in Low- and Middle-Income Countries: A Scoping Review

BACKGROUND

Understanding the cost of delivering breast cancer (BC) care in low- and middle-income countries (LMICs) is critical to guide effective care delivery strategies. This scoping review summarizes the scope of literature on the costs of BC care in LMICs and characterizes the methodological approaches of these economic evaluations.

MATERIALS AND METHODS

A systematic literature search was performed in five databases and gray literature up to March 2020. Studies were screened to identify original articles that included a cost outcome for BC diagnosis or treatment in an LMIC. Two independent reviewers assessed articles for eligibility. Data related to study characteristics and methodology were extracted. Study quality was assessed using the Drummond et al. checklist.

RESULTS

Ninety-one articles across 38 countries were included. The majority (73%) of studies were published between 2013 and 2020. Low-income countries (2%) and countries in Sub-Saharan Africa (9%) were grossly underrepresented. The majority of studies (60%) used a health care system perspective. Time horizon was not reported in 30 studies (33%). Of the 33 studies that estimated the cost of multiple steps in the BC care pathway, the majority (73%) were of high quality, but studies varied in their inclusion of nonmedical direct and indirect costs.

CONCLUSION

There has been substantial growth in the number of BC economic evaluations in LMICs in the past decade, but there remain limited data from low-income countries, especially those in Sub-Saharan Africa. BC economic evaluations should be prioritized in these countries. Use of existing frameworks for economic evaluations may help achieve comparable, transparent costing analyses.

IMPLICATIONS FOR PRACTICE

There has been substantial growth in the number of breast cancer economic evaluations in low- and middle-income countries (LMICs) in the past decade, but there remain limited data from low-income countries. Breast cancer economic evaluations should be prioritized in low-income countries and in Sub-Saharan Africa. Researchers should strive to use and report a costing perspective and time horizon that captures all costs relevant to the study objective, including those such as direct nonmedical and indirect costs. Use of existing frameworks for economic evaluations in LMICs may help achieve comparable, transparent costing analyses in order to guide breast cancer control strategies.

Cost of breast cancer care in low- and middle-income countries: a scoping review protocol

OBJECTIVE

This review will describe the scope of the literature on the cost of breast cancer care in low- and middle-income countries and summate the methodological characteristics and approaches of these economic evaluations.

INTRODUCTION

In the past decade, there has been global momentum to improve capacity for breast cancer care in low- and middle-income countries, which have higher rates of breast cancer mortality compared to high-income countries. Understanding the cost of delivering breast cancer care in low- and middle-income countries is critical to guide effective cancer care delivery strategies and policy.

INCLUSION CRITERIA

Studies that estimate the cost of breast cancer diagnosis and treatment in low- and middle-income countries will be included. Studies not available in English will be excluded.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review guidelines will be utilized. The search strategy has been developed in consultation with a medical librarian and will be carried out on five electronic databases from their inception (MEDLINE, Embase, Web of Science, Global Health, WHO Global Index Medicus) as well as in gray literature sources. Two independent reviewers will review all abstracts and titles in the primary screen and full-text articles in the secondary screen. A third reviewer will adjudicate conflicts. One reviewer will perform data extraction. Study demographics, design, and methodological characteristics (such as costing perspective, time horizon, and included cost categories) will be summarized in narrative and tabular formats. The methodological quality of studies will be evaluated using a validated economic evaluation tool.

Mapping breast cancer journal publications in conflict settings in the MENA region: a scoping review

Background

Breast cancer is a major cause of cancer-related morbidity and mortality among women in the the Middle East and North Africa (MENA) region. Conflict and political instability in the region may affect medical research output, including that on breast cancer. This scoping review aims to systematically identify and map breast cancer publications across different stages of the cancer care pathway and across conflict-affected countries within the MENA region. The findings of this work will highlight the impact of conflict on cancer research that could be mitigated with the proper contextualised capacity strengthening intervention.

Methods

We followed the PRISMA-Scr methodology. We searched for peer-reviewed publications on topics related to breast cancer in 11 databases: Medline, PubMed, EMBASE, Web of Science, PROQUEST, CINAHL, Global Index Medicus, Arab World Searches Complete, Popline, Scopus and Google Scholar using both controlled vocabulary and keywords. Publication abstracts and full-text versions were screened for duplicates and included in our study based on pre-specified eligibility criteria: focused on breast cancer, related to the specific country of analysis and human or health system studies. We used a structured data extraction form to extract information related to the article, its methodology and the cancer care pathway being studied.

Results

A total of 19,215 citations were retrieved from our search. After removing duplicates, a total of 8,622 articles remained. Title and abstract screening retained 1,613 articles. Publications with first author affiliations to Turkey were consistently the highest across all categories of the cancer care pathway. Trends show an increase in articles from Lebanon, Jordan and Palestine after 2015. Early exploratory and epidemiological studies represented the majority of breast cancer research, followed by policy and implementation research and lastly experimental research. Most research conducted followed an observational study design. Important gaps were identified in the research output related to advanced breast cancer and palliative care (Libya, Syria and Yemen), mental health (Libya), and knowledge and education of breast cancer (Libya and Syria).

Conclusion

This scoping review has identified key areas in breast cancer research that lack significant research activity in conflict MENA settings. These areas, including but are not limited to palliative care, mental health, and education, can be prioritised and developed through regional collaboration and contextualised capacity strengthening initiatives.

Cost-effectiveness analyses of breast cancer medications use in developing countries: a systematic review

BACKGROUND

Pharmacoeconomic evaluation is important for breast-cancer medications due to their high costs. To our knowledge, no systematic literature reviews of pharmacoeconomic studies for breast-cancer medication use are present in developing-countries.

OBJECTIVES

To systematically review the existing cost-effectiveness evaluations of breast-cancer medication in developing-countries.

METHODOLOGY

A systematic literature search was performed in PubMed, EMBASE, SCOPUS, and EconLit. Two researchers determined the final articles, extracted data, and evaluated their quality using the Quality of Health-Economic Studies (QHES) tool. The interclass-correlation-coefficient (ICC) was calculated to assess interrater-reliability. Data were summarized descriptively.

RESULTS

Fourteen pharmacoeconomic studies published from 2009 to 2019 were included. Thirteen used patient-life-years as their effectiveness unit, of which 10 used quality-adjusted life-years. Most of the evaluations focused on trastuzumab as a single agent or on regimens containing trastuzumab (n = 10). The conclusion of cost-effectiveness analysis varied among the studies. All the studies were of high quality (QHES score >75). Interrater reliability between the two reviewers was high (ICC = 0.76).

CONCLUSION

In many studies included in the review, the use of breast-cancer drugs in developing countries was not cost-effective. Yet, more pharmacoeconomic evaluations for the use of recently approved agents in different disease stages are needed in developing countries.

Real-World Clinical and Economic Outcomes Associated with Palbociclib for HR-Positive/HER2 Negative Metastatic Breast Cancer: A Commentary

Despite the achieved advancement in pharmacological cancer treatments, the majority of postmenopausal women with hormone receptor-positive metastatic breast cancer (mBC) will experience disease progression. Research into alternative therapies with improved efficacy and reduced side effects has led to the development of a new class of oral anticancer medications, the cyclin-dependent kinase (CDK) 4/6 inhibitors, which include palbociclib, ribociclib, and abemaciclib. Nonetheless, there is growing evidence that the effectiveness of oral anticancer medications is sub-optimal, being influenced by low adherence, sociodemographic factors, and adverse effect profiles. In addition, there is a disconnect between the high price tags of CDK 4/6 inhibitors and their observed effectiveness, raising questions about their value. Currently, the existing knowledge base on the effectiveness and cost-effectiveness of newer oral anticancer medications in understudied populations with possible health disparities is scant. This commentary discusses what is known about palbociclib's clinical effectiveness, safety, and adherence and suggests the need for further studies of real-world effectiveness and cost-effectiveness to help establish the value of newer oncologic drugs, such as palbociclib. DISCLOSURES: No funding supported the writing of this article. The authors have nothing to disclose.

Analysis of Mammography Screening Schedules under Varying Resource Constraints for Planning Breast Cancer Control Programs in Low- and Middle-Income Countries: A Mathematical Study

Background. Low-and-middle-income countries (LMICs) have higher mortality-to-incidence ratio for breast cancer compared to high-income countries (HICs) because of late-stage diagnosis. Mammography screening is recommended for early diagnosis, however, the infrastructure capacity in LMICs are far below that needed for adopting current screening guidelines. Current guidelines are extrapolations from HICs, as limited data had restricted model development specific to LMICs, and thus, economic analysis of screening schedules specific to infrastructure capacities are unavailable. Methods. We applied a new Markov process method for developing cancer progression models and a Markov decision process model to identify optimal screening schedules under a varying number of lifetime screenings per person, a proxy for infrastructure capacity. We modeled Peru, a middle-income country, as a case study and the United States, an HIC, for validation. Results. Implementing 2, 5, 10, and 15 lifetime screens would require about 55, 135, 280, and 405 mammography machines, respectively, and would save 31, 62, 95, and 112 life-years per 1000 women, respectively. Current guidelines recommend 15 lifetime screens, but Peru has only 55 mammography machines nationally. With this capacity, the best strategy is 2 lifetime screenings at age 50 and 56 years. As infrastructure is scaled up to accommodate 5 and 10 lifetime screens, screening between the ages of 44-61 and 41-64 years, respectively, would have the best impact. Our results for the United States are consistent with other models and current guidelines. Limitations. The scope of our model is limited to analysis of national-level guidelines. We did not model heterogeneity across the country. Conclusions. Country-specific optimal screening schedules under varying infrastructure capacities can systematically guide development of cancer control programs and planning of health investments.

Cost-Effectiveness of Lifestyle-Related Interventions for the Primary Prevention of Breast Cancer: A Rapid Review

Background: In 2018, the global estimate of newly diagnosed breast cancer cases among women totaled 2.1 million. The economic and social burden that breast cancer places on societies has propelled research that analyzes the role of modifiable risk factors as the primary prevention methods. Healthy behavior changes, moderated alcohol intake, healthy body weight, and regular physical activity may decrease the risk of breast cancer among women. This review aimed to synthesize evidence on the cost-effectiveness of lifestyle-related interventions for the primary prevention of breast cancer in order to answer the question on whether implementing interventions focused on behavior changes are worth the value for money.

Methods: A rapid review was performed using search terms developed by the research team. The articles were retrieved from MEDLINE and the Tufts Medical Center Cost-Effectiveness Analysis Registry, with an additional web search in Google and Google Scholar. Comparisons were performed on the cost-effectiveness ratio per quality-adjusted life-year between the interventions using a league table, and the likelihood of cost-effective interventions for breast cancer primary prevention was analyzed.

Results: Six studies were selected. The median cost-effectiveness ratio (in 2018 USD) was $24,973, and 80% of the interventions had a ratio below the $50,000 threshold. The low-fat-diet program for postmenopausal women was cost-effective at a societal level, and the physical activity interventions, such as the Be Active Program in the UK, had the best cost saving results. A total of 11 of the 25 interventions ranked either as highly or very highly likely to be cost-effective for breast cancer primary preventions.

Conclusion: Although the review had some limitations due to using only a few studies, it showed evidence that diet-related and physical-activity-related interventions for the primary prevention of breast cancer were cost-effective. Many of the cost-effective interventions aimed to reduce the risk of non-communicable diseases alongside breast cancer.

Systematic reviews as a "lens of evidence": Determinants of cost-effectiveness of breast cancer screening

Systematic reviews with economic components are important decision tools for stakeholders seeking to evaluate technologies, such as breast cancer screening (BCS) programs. This overview of systematic reviews explores the determinants of the cost-effectiveness of BCS and assesses the quality of secondary evidence. The search identified 30 systematic reviews that reported on the determinants of the cost-effectiveness of BCS, including the costs of breast cancer and BCS. While the quality of the reviews varied widely, only four out of 30 papers were considered to be of a high quality. We did not identify publication bias in the original evidence on the cost-effectiveness of mammography screening; however, we highlight a need for improved clarity in both reporting and data verification. The reviews consisted mainly of studies from high-income countries. Breast cancer costs varied widely among the studies. Factors leading to higher costs included: time (diagnosis and last months before death), later stage or metastases, recurrence of the disease, age below 64 years and type of follow-up (more intensive or more specialized). Overall, screening with mammography was considered cost-effective in the age range 50-69 years in Western European and Northern American countries but not for older or younger women. Its cost-effectiveness was questionable for low-income settings and Asia. Mammography screening was more cost-effective with biennial screening compared to annual screening and single reading using computer-aided detection vs double reading. No information on the cost-effectiveness of ultrasonography was found, and there is much uncertainty on the cost-effectiveness of CBE because of methodological limitations.

Impacts of self-care education on adverse events and mental health related quality of life in breast cancer patients under chemotherapy

OBJECTIVE

As a consequence of its high incidence, breast cancer has become a severe health risk in women. Chemotherapy is one of the main treatments for breast cancer, but causes a decline in life quality of patients. Self-care is a non-medical intervention and has been reported to improve the life quality of colorectal cancer patients. We aim to explore whether self-care is also effective in breast cancer.

MATERIALS AND METHODS

85 breast cancer patients under chemotherapy participated in this research, among whom 44 patients received the self-care education. The physical and mental conditions of patients before and after chemotherapy were evaluated by Anxiety Inventory, Rotterdam Symptom checklists and QLQ-C30.

RESULTS

The result showed that the occurrence rates of symptoms were significantly reduced after self-care measures. Anxiety Inventory and Rotterdam Symptom checklists indicated that self-care measures could improve both the physical and mental conditions of patients. The Global Quality of Life (QoL) from QLQ-C30 questionnaire further confirmed the effectiveness of self-care measures in breast cancer patients.

CONCLUSIONS

Based on the results, self-care measures are effective in improving the physical and mental conditions of breast cancer patients under chemotherapy. Self-care measures play an important role in improving patients' life quality.

A Two-Step Markov Processes Approach for Parameterization of Cancer State-Transition Models for Low- and Middle-Income Countries

Implementation of organized cancer screening and prevention programs in high-income countries (HICs) has considerably decreased cancer-related incidence and mortality. In low- and middle-income countries (LMICs), screening and early diagnosis programs are generally unavailable, and most cancers are diagnosed in late stages when survival is very low. Analyzing the cost-effectiveness of alternative cancer control programs and estimating resource needs will help prioritize interventions in LMICs. However, mathematical models of natural cancer onset and progression needed to conduct the economic analyses are predominantly based on populations in HICs because the longitudinal data on screening and diagnoses required for parameterization are unavailable in LMICs. Models currently used for LMICs mostly concentrate on directly calculating the shift in distribution of cancer diagnosis as an evaluative measure of screening. We present a mathematical methodology for the parameterization of natural cancer onset and progression, specifically for LMICs that do not have longitudinal data. This full onset and progression model can help conduct comprehensive analyses of cancer control programs, including cancer screening, by considering both the positive impact of screening as well as any adverse consequences, such as over-diagnosis and false-positive results. The methodology has been applied to breast, cervical, and colorectal cancers for 2 regions, under the World Health Organization categorization: Eastern Sub-Saharan Africa (AFRE) and Southeast Asia (SEARB). The cancer models have been incorporated into the Spectrum software and interfaced with country-specific demographic data through the demographic projections (DemProj) module and costing data through the OneHealth tool. These software are open-access and can be used by stakeholders to analyze screening strategies specific to their country of interest.

Refining a questionnaire to assess breast cancer knowledge and barriers to screening in Kenya: Psychometric assessment of the BCAM

Background

Our study objective was to determine the validity and reliability of the breast module of a cancer awareness measure (BCAM) among adult women in western Kenya.

Methods

The study was conducted between October and November 2012, following three breast cancer screening events. Purposive and systematic random sampling methods were used to identity 48 women for cognitive focus group discussions, and 1061 (594 who attended vs. 467 who did not attend screening events) for surveys, respectively. Face and psychometric validity of the BCAM survey was assessed using cognitive testing, factor analysis of survey data, and correlations. Internal reliability was assessed using Cronbach’s alpha.

Results

Among survey participants, the overall median age was 34 (IQR: 26–44) years. Compared to those women who did not attend the screening events, women attendees were older (median: 35 vs. 32 years, p = 0.001) more often married (79% vs. 72%, p = 0.006), more educated (52% vs. 46% with more than an elementary level of education, p = 0.001), more unemployed (59% vs. 11%, p = 0.001), more likely to report doing breast self-examination (56% vs. 40%, p = 0.001) and more likely to report having felt a breast lump (16% vs. 7%, p = 0.001). For domain 1 on knowledge of breast cancer symptoms, one factor (three items) with Eigen value of 1.76 emerged for the group that did not attend screening, and 1.50 for the group that attended screening. For both groups two factors (factor 1 “internal influences” and factor 2 “external influences”) emerged among domain 4 on barriers to screening, with varied item loadings and Eigen values. There were no statistically significant differences in the factor scores between attendees and non-attendees. There were significant associations between factor scores and other attributes of the surveyed population, including associations with occupation, transportation type, and training for and practice of breast self-examination. Cronbach’s alpha showed an acceptable internal consistency.

Conclusion

Certain subpopulations are less likely than others to attend breast screening in Kenya. A survey measure of breast cancer knowledge and perceived barriers to screening shows promise for use in Kenya for characterizing clinical and community population beliefs, but needs adaptation for setting, language and culture.

A Systematic Review of Health Economic Analyses of Housing Improvement Interventions and Insecticide-Treated Bednets in the Home

Background

Housing improvements have considerable potential for improving health. So does the provision of insecticide-treated bednets for malaria prevention. Therefore we aimed to conduct updated systematic reviews of health economic analyses in both these intervention domains.

Methods and findings

The search strategy included economic analyses of housing improvement interventions and use of insecticide-treated bednets for community-dwelling, healthy populations (published between 1 January 2000 and 15 April 2014). We searched the Cochrane Database of Systematic Reviews, MEDLINE, PubMed, EMBASE, and three health economics databases. Thirty-five economic analyses of seven types of intervention fulfilled the inclusion criteria. Most included studies adopted a health sector perspective and were cost-effectiveness analyses using decision analytic modeling or conducted alongside trials. The overall quality of the studies was generally likely to be adequate for informing policy-making (albeit with limitations in some areas). There was fairly consistent evidence for the cost-effectiveness/favorable cost-benefit of removing indoor lead to prevent lead poisoning and sequelae, and retrofitting insulation to prevent lung disease. But the value of assessing and improving home safety and providing smoke alarms to prevent injuries was more mixed and the economic evidence was inconclusive or insufficient for: home ventilation to prevent lung disease, installing heaters to prevent lung disease and regulating tap water temperatures to prevent scalding. Few studies (n = 4) considered health equity. The 12 studies of providing insecticide-treated bednets or hammocks to prevent malaria found these interventions to be moderately to highly cost-effective.

Conclusions

This systematic review provides updated evidence that several housing improvement interventions (such as removing indoor lead and retrofitting insulation) and also the provision of insecticide-treated bednets are cost-effective interventions. Nevertheless, for some interventions additional analyses are required to better clarify their health economic and health equity value.

Systematic Review and Quality Appraisal of Economic Evaluation Publications in Dentistry

Economic evaluation (EE) studies have been undertaken in dentistry since the late 20th century because economic data provide additional information to policy makers to develop guidelines and set future direction for oral health services. The objectives of this study were to assess the methodological quality of EEs in oral health. Electronic searching of Ovid MEDLINE, the Cochrane Library, and the NHS Economic Evaluation Database from 1975 to 2013 were undertaken to identify publications that include costs and outcomes in dentistry. Relevant reference lists were also searched for additional studies. Studies were retrieved and reviewed independently for inclusion by 3 authors. Furthermore, to appraise the EE methods, 1 author applied the Drummond 10-item (13-criteria) checklist tool to each study. Of the 114 publications identified, 79 studies were considered full EE and 35 partial. Twenty-eight studies (30%) were published between the years 2011 and 2013. Sixty-four (53%) studies focused on dental caries prevention or treatment. Median appraisal scores calculated for full and partial EE studies were 11 and 9 out of 13, respectively. Quality assessment scores showed that the quality of partial EE studies published after 2000 significantly improved (P = 0.02) compared to those published before 2000. Significant quality improvement was not found in full EE studies. Common methodological limitations were identified: absence of sensitivity analysis, discounting, and insufficient information on how costs and outcomes were measured and valued. EE studies in dentistry increased over the last 40 y in both quantity and quality, but a number of publications failed to satisfy some components of standard EE research methods, such as sensitivity analysis and discounting.

Developing the Evidence Base to Inform Best Practice: A Scoping Study of Breast and Cervical Cancer Reviews in Low- and Middle-Income Countries

BACKGROUND

Breast and cervical cancers have emerged as major global health challenges and disproportionately lead to excess morbidity and mortality in low- and middle-income countries (LMICs) when compared to high-income countries. The objective of this paper was to highlight key findings, recommendations, and gaps in research and practice identified through a scoping study of recent reviews in breast and cervical cancer in LMICs.

METHODS

We conducted a scoping study based on the six-stage framework of Arskey and O'Malley. We searched PubMed, Cochrane Reviews, and CINAHL with the following inclusion criteria: 1) published between 2005-February 2015, 2) focused on breast or cervical cancer 3) focused on LMIC, 4) review article, and 5) published in English.

RESULTS

Through our systematic search, 63 out of the 94 identified cervical cancer reviews met our selection criteria and 36 of the 54 in breast cancer. Cervical cancer reviews were more likely to focus upon prevention and screening, while breast cancer reviews were more likely to focus upon treatment and survivorship. Few of the breast cancer reviews referenced research and data from LMICs themselves; cervical cancer reviews were more likely to do so. Most reviews did not include elements of the PRISMA checklist.

CONCLUSION

Overall, a limited evidence base supports breast and cervical cancer control in LMICs. Further breast and cervical cancer prevention and control studies are necessary in LMICs.

A review of systematic reviews of the cost-effectiveness of hormone therapy, chemotherapy, and targeted therapy for breast cancer

Breast cancer is a global health concern. In fact, breast cancer is the primary cause of death among women worldwide and constitutes the most expensive malignancy to treat. As health care resources are finite, decisions regarding the adoption and coverage of breast cancer treatments are increasingly being based on "value for money," i.e., cost-effectiveness. As the evidence about the cost-effectiveness of breast cancer treatments is abundant, therefore difficult to navigate, systematic reviews of published systematic reviews offer the advantage of bringing together the results of separate systematic reviews in a single report. As a consequence, this paper presents an overview of systematic reviews of the cost-effectiveness of hormone therapy, chemotherapy, and targeted therapy for breast cancer to inform policy and reimbursement decision-making. A systematic review was conducted of published systematic reviews documenting cost-effectiveness analyses of breast cancer treatments from 2000 to 2014. Systematic reviews identified through a literature search of health and economic databases were independently assessed against inclusion and exclusion criteria. Systematic reviews of original evaluations were included only if they targeted breast cancer patients and specific breast cancer treatments (hormone therapy, chemotherapy, and targeted therapy only), documented incremental cost-effectiveness ratios, and were reported in the English language. The search strategy used a combination of these key words: "breast cancer," "systematic review/meta-analysis," and "cost-effectiveness/economics." Data were extracted using predefined extraction forms and qualitatively appraised using the assessment of multiple systematic reviews (AMSTAR) tool. The literature search resulted in 511 bibliographic records, of which ten met our inclusion criteria. Five reviews were conducted in the early-stage breast cancer setting and five reviews in the metastatic setting. In early-stage breast cancer, evidence about trastuzumab value differed by age. Trastuzumab was cost-effective only in women with HER2-positive breast cancer younger than 65 years and over a life-time horizon. The cost-effectiveness of trastuzumab in HER2-positive metastatic breast cancer yielded conflicting results. The same conclusions were reached in comparisons between vinorelbine and taxanes. In both early stage and advanced/metastatic breast cancer, newer aromatase inhibitors (AIs) have proved cost-effective compared to older treatments. This overview of systematic reviews shows that there is heterogeneity in the evidence concerning the cost-effectiveness of hormone therapy, chemotherapy, and targeted therapy for breast cancer. The cost-effectiveness of these treatments depends not only on the comparators but the context, i.e., adjuvant or metastatic setting, subtype of patient population, and perspective adopted. Decisions involving the cost-effectiveness of breast cancer treatments could be made easier and more transparent by better harmonizing the reporting of economic evaluations assessing the value of these treatments.

A systematic review and quality appraisal of international guidelines for early breast cancer systemic therapy: Are recommendations sensitive to different global resources?

The breast cancer incidence in low and middle income countries (LMCs) is increasing globally, and patient outcomes are generally worse in these nations compared to high income countries (HICs). This is partly due to resource constraints associated with implementing recommended breast cancer therapies. Clinical practice guideline (CPG) adherence can improve breast cancer outcomes, however, many CPGs are created in HICs, and include costly recommendations that may not be feasible in LMCs. In addition, the quality of CPGs can be variable. The aim of this study was to perform a systematic review of CPGs on early breast cancer systemic therapy with potential international impact, to evaluate their content, quality, and resource sensitivity. A MEDLINE and gray literature search was completed for English language CPGs published between 2005 and 2010, and then updated to July 2014. Extracted guidelines were evaluated using the AGREE 2 instrument. Guidelines were specifically analyzed for resource sensitivity. Most of the extracted CPGs had similar recommendations with regards to systemic therapy. However, only one, the Breast Health Global Initiative, made recommendations with consideration of different global resources. Overall, the CPGs were of variable quality, and most scored poorly in the quality domain evaluating implementation barriers such as resources. Published CPGs for early breast cancer are created in HICs, have similar recommendations, and are generally resource-insensitive. Given the visibility and influence of these CPGs on LMCs, efforts to create higher quality, resource-sensitive guidelines with less redundancy are needed.

Quality assessment of economic evaluation studies in pediatric surgery: a systematic review

PURPOSE

To assess economic evaluation studies (EES) in pediatric surgery and to identify potential factors associated with high-quality studies.

METHODS

A systematic review of the literature using PubMed and Cochrane databases was conducted to identify EES in pediatric surgery published between 1 June 1993 and 30 June 2013. Assessment criteria are derived from the Drummond checklist. A high quality study was defined as a Drummond score ≥7. Logistic regression analysis was used to determine factors associated with high quality studies.

RESULTS

119 studies were included. 43.7% (n=52) of studies were full EES. Cost-effectiveness analysis was the most frequent (61.5%) type of full EES. Only 31.6% of studies had a Drummond score ≥7 and 73% of these were full EES. The factors associated with high quality were identification of costs (OR: 14.08; 95% CI: 3.38-100; p<0.001), estimation of utility value (OR: 8.13; 95% CI: 2.02-43.47; p=0.005) and study funding (OR: 3.50; 95% CI: 1.27-10.10; p=0.02).

CONCLUSION

This review shows that the number and the quality of EES are low despite the increasing number of studies published in recent years. In the current context of budget constraints, our results should encourage pediatric surgeons to focus more on EES.

Predicting the stage shift as a result of breast cancer screening in low- and middle-income countries: a proof of concept

OBJECTIVE

To provide proof of concept for a simple model to estimate the stage shift as a result of breast cancer screening in low- and middle-income countries (LMICs). Stage shift is an essential early detection indicator and an important proxy for the performance and possible further impact of screening programmes. Our model could help LIMCs to choose appropriate control strategies.

METHODS

We assessed our model concept in three steps. First, we calculated the proportional performance rates (i.e. index number Z) based on 16 screening rounds of the Nijmegen Screening Program (384,884 screened women). Second, we used linear regression to assess the association between Z and the amount of stage shift observed in the programme. Third, we hypothesized how Z could be used to estimate the stage shift as a result of breast cancer screening in LMICs.

RESULTS

Stage shifts can be estimated by the proportional performance rates (Zs) using linear regression. Zs calculated for each screening round are highly associated with the observed stage shifts in the Nijmegen Screening Program (Pearson's R: 0.798, R square: 0.637).

CONCLUSIONS

Our model can predict the stage shifts in the Nijmegen Screening Program, and could be applied to settings with different characteristics, although it should not be straightforwardly used to estimate the impact on mortality. Further research should investigate the extrapolation of our model to other settings. As stage shift is an essential screening performance indicator, our model could provide important information on the performance of breast cancer screening programmes that LMICs consider implementing.

Implementation science in cancer prevention and control: a framework for research and programs in low- and middle-income countries

Implementation science is a set of tools, principles, and methodologies that can be used to bring scientific evidence into action, improve health care quality and delivery, and improve public health. As the burden of cancer increases in low- and middle-income countries, it is important to plan cancer control programs that are both evidence based and delivered in ways that are feasible, cost-effective, contextually appropriate, and sustainable. This review presents a framework for using implementation science for cancer control planning and implementation and discusses potential areas of focus for research and programs in low- and middle-income countries interested in integrating research into practice and policy.

Preventing breast cancer in LMICs via screening and/or early detection: The real and the surreal

To review the present status of breast cancer (BC) screening/early detection in low- and middle-income countries (LMICs) and identify the way forward, an open focused search for articles was undertaken in PubMed, Google Scholar and Google, and using a snowball technique, further articles were obtained from the reference list of initial search results. In addition, a query was put up on ResearchGate to obtain more references and find out the general opinion of experts on the topic. Experts were also personally contacted for their opinion. Breast cancer (BC) is the most common cancer in women in the world. The rise in incidence is highest in LMICs where the incidence has often been much lower than high-income countries. In spite of more women dying of cancer than pregnancy or childbirth related causes in LMICs, most of the focus and resources are devoted to maternal health. Also, the majority of women in LMICs present at late stages to a hospital to initiate treatment. A number of trials have been conducted in various LMICs regarding the use of clinical breast examination and mammography in various combinations to understand the best ways of implementing a population level screening/early detection of BC; nevertheless, more research in this area is badly needed for different LMIC specific contexts. Notably, very few LMICs have national level programs for BC prevention via screening/early detection and even stage reduction is not on the public health agenda. This is in addition to other barriers such as lack of awareness among women regarding BC and the presence of stigma, inappropriate attitudes and lack of following proper screening behavior, such as conducting breast self-examinations. The above is mixed with the apathy and lack of awareness of policy makers regarding the fact that BC prevention is much more cost-effective and humane than BC treatment. Implementation of population level programs for screening/early detection of BC, along with use of ways to improve awareness of women regarding BC, can prove critical in stemming the increasing burden of BC in LMICs. Use of newer modalities such as ultrasonography which is more suited to LMIC populations and use of mHealth for awareness creation and increasing screening compliance are much needed extra additions to the overall agenda of LMICs in preventing BC.

Cost-effectiveness analysis of breast cancer control interventions in Peru

Objectives

In Peru, a country with constrained health resources, breast cancer control is characterized by late stage treatment and poor survival. To support breast cancer control in Peru, this study aims to determine the cost-effectiveness of different breast cancer control interventions relevant for the Peruvian context.

Methods

We performed a cost-effectiveness analysis (CEA) according to WHO-CHOICE guidelines, from a healthcare perspective. Different screening, early detection, palliative, and treatment interventions were evaluated using mathematical modeling. Effectiveness estimates were based on observational studies, modeling, and on information from Instituto Nacional de Enfermedades Neoplásicas (INEN). Resource utilizations and unit costs were based on estimates from INEN and observational studies. Cost-effectiveness estimates are in 2012 United States dollars (US$) per disability adjusted life year (DALY) averted.

Results

The current breast cancer program in Peru ($8,426 per DALY averted) could be improved through implementing triennial or biennial screening strategies. These strategies seem the most cost-effective in Peru, particularly when mobile mammography is applied (from $4,125 per DALY averted), or when both CBE screening and mammography screening are combined (from $4,239 per DALY averted). Triennially, these interventions costs between $63 million and $72 million per year. Late stage treatment, trastuzumab therapy and annual screening strategies are the least cost-effective.

Conclusions

Our analysis suggests that breast cancer control in Peru should be oriented towards early detection through combining fixed and mobile mammography screening (age 45-69) triennially. However, a phased introduction of triennial CBE screening (age 40-69) with upfront FNA in non-urban settings, and both CBE (age 40-49) and fixed mammography screening (age 50-69) in urban settings, seems a more feasible option and is also cost-effective. The implementation of this intervention is only meaningful if awareness raising, diagnostic, referral, treatment and basic palliative services are simultaneously improved, and if financial and organizational barriers to these services are reduced.