Cost-effectiveness and Benefit-to-Harm Ratio of Risk-Stratified Screening for Breast Cancer: A Life-Table Model.
Publication Date
2018-11Journal Title
JAMA oncology
ISSN
2374-2437
Volume
4
Issue
11
Pages
1504-1510
Language
eng
Type
Article
This Version
VoR
Physical Medium
Print
Metadata
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Pashayan, N., Morris, S., Gilbert, F., & Pharoah, P. (2018). Cost-effectiveness and Benefit-to-Harm Ratio of Risk-Stratified Screening for Breast Cancer: A Life-Table Model.. JAMA oncology, 4 (11), 1504-1510. https://doi.org/10.1001/jamaoncol.2018.1901
Abstract
Abstract
Importance The age-based or the ‘one-size-fits-all’ screening approach does not take into account the
individual variation in risk. Mammography screening reduces death from breast cancer at a cost of
overdiagnosis. Identifying risk-stratified screening strategies with more favourable ratio of
overdiagnoses to breast cancer deaths prevented would improve quality of life of women and save
resources.
Objective To assess the benefit to harm balance and the cost-effectiveness of risk-stratified breast
screening programmes compared with standard age-based screening programme and no screening.
Design A life table model using findings of the Independent UK Panel on Breast Cancer Screening and
risk distribution based on polygenic risk profile.
Setting United Kingdom. The analysis was from the National Health Service perspective.
Population and interventions Hypothetical cohort of 365,400 women aged 50 years followed-up to
age 85. The interventions were no screening, age-based screening (mammography screening every
three years from age 50-69 years), and risk-stratified screening (a proportion of women aged 50 with a
risk score greater than a threshold risk were offered screening every three years until age 69)
considering each percentile of the risk distribution.
Main outcome measures Overdiagnoses, breast cancer deaths averted, quality adjusted life years
(QALYs) gained, costs, and net monetary benefit (NMB). Probabilistic sensitivity analyses assessed
uncertainty around parameter estimates. Future costs and benefits were discounted at 3.5% per year.
Results In risk-stratified screening, compared to no screening, as the risk threshold was lowered, the
incremental cost of the programme increased linearly with no additional QALYs gained below 35th
percentile risk threshold. Of the screening scenarios – no screening, age-based, and risk-stratified - the
scenario with risk threshold at the 70th percentile had the highest NMB at willingness to pay of £20,000
per QALY gained, with a 72% probability of being cost-effective. Compared with age-based screening,
4
risk-targeted screening at 32nd vs. 70th percentile risk threshold would cost £20,066 vs. £537,985 less,
have 9.6% vs. 71% fewer overdiagnoses while averting 2.9% vs. 9.6% fewer breast cancer deaths,
respectively.
Conclusion Not offering screening to women at lower risk would improve the cost-effectiveness of the
screening programme, reduce overdiagnosis while maintaining the benefits of screening.
Keywords
Humans, Breast Neoplasms, Risk Assessment, Aged, Middle Aged, Cost-Benefit Analysis, Female, Early Detection of Cancer
Sponsorship
Cancer Research UK (10119)
Engineering and Physical Sciences Research Council (EP/P006485/1)
Embargo Lift Date
2100-01-01
Identifiers
External DOI: https://doi.org/10.1001/jamaoncol.2018.1901
This record's URL: https://www.repository.cam.ac.uk/handle/1810/278416
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