Advances in Women's Health
Cost-effectiveness analysis of breast cancer screening by mammography in average-risk women in China
Xudong Chen1,2*
1Shenzhen China Resources Gosun Pharmaceutical Co. Ltd, Shenzhen 518049, China
2China Resources Sanjiu Medical & Pharmaceutical Co. Ltd, Shenzhen, China
*Corresponding author: Xudong Chen, MS, Shenzhen China Resources Gosun Pharmaceutical Co. Ltd, Shenzhen 518049, China. E-mail: chenxudong60@163.com
DOI: 10.17352/awh.000001
Received: 23 November, 2023 | Accepted: 18 December, 2023 | Published: 19 December, 2023
Keywords: Breast cancer; Mammography; Screening; Average-risk women; Cost-effectiveness analysis; China
Cite this as
Chen X (2023) Cost-effectiveness analysis of breast cancer screening by mammography in average-risk women in China. Adv Women’s Health. 1(1): 001-004. DOI: 10.17352/awh.000001
Copyright Licence
© 2023 Chen X. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Breast cancer is the most common form of cancer among women worldwide and is often at an advanced stage when clinical diagnosis. Fortunately, mammography could increase the detection rate of early-stage breast cancer. In this study, we conducted a cost-effectiveness analysis of breast cancer screening compared with no screening for average-risk women aged 45-69 every two years in China. Parameters about screening, costs, and utilities were taken from previous studies. Compared with no screening, mammography screening cost $1566.12 more with a reduction of 0.0088 Quality-Adjusted Life Years (QALYs), which was absolutely dominated. In summary, breast cancer screening by mammography was more recommended to high-risk women rather than average-risk women in China.
Introduction
Breast cancer is a continuing major global public health concern for all women. As a result, breast cancer screening was recommended for high-risk women aged 40 to 69 every year and for average-risk women aged 45 to 69 every 2 years according to China Guideline for the Screening and Early Detection of Female Breast Cancer [1]. Current methods of screening involve clinical breast examination, mammography, ultrasonic examination as well as Magnetic Resonance Imaging (MRI), during which mammography was the most recommended according to clinical practice guidelines [2,3]. Previous study in China has shown that compared with no screening, annual screening for high-risk women is cost-effective [4]. However, further exploration is needed for average-risk women. In this study, we aimed to develop a Markov model to evaluate the cost-effectiveness of breast cancer screening by mammography for average-risk women in China. The time horizon was 45 years (from 40 to 85 years) and the cycle length was one year.
Methods
We compared the current recommended strategy for average-risk women with no screening. The screening process is shown in Figure 1. Breast Imaging Reporting and Data System (BI-RADS) I and II represent negative results. BI-RADS IV and V represent positive results, and BI-RADS 0 and III represent insufficient and suspicious results [5]. Those with positive results, and insufficient or suspicious results will undergo a biopsy, others repeat screening 2 years later.
Figure 1: Screening process. BI-RADS; Breast Imaging Reporting and Data System.
A Markov model was developed using TreeAge software as shown in Figure 2. The model consisted of twelve states. Women who develop breast cancer could remain in the current stage, progress to a higher stage, be diagnosed by symptoms or screening, or expire due to breast cancer or other cause. The age-specific invasive breast cancer incidence was taken from the Chinese Cancer Registry Annual Report [6]. The transition probability of natural history was obtained from previous studies [4,7,8]. After diagnosis, stage-specific mortality rates were estimated from Surveillance, Epidemiology and End Results (SEER) Program data [9,10].
Figure 2: Markov model.
The effectiveness of screening came from a system review which included 56 studies [1]. The distribution characteristic of BI-RADS was from a breast cancer screening in Guangdong province in 2021 [11].
The cost of screening was taken from the rural breast cancer screening programme, during which the cost of mammography and biopsy were $29.75 and $23.80, respectively [7,12 ]. Moreover, we derived the treatment cost from the Urban Cancer Early Detection and Treatment Program in Hebei province [13].
The utility was extracted from a previous study and we assumed that those with Ductal Carcinoma in Situ (DCIS) have the same utility as those without breast cancer [14,15]. A disutility lasted for 3 months for false positive was also assumed in our model.
Cost and QALYs would be discounted by 5% per year. A half-cycle correction was also applied. The key input parameters are presented in Table 1. Finally, the incremental cost, incremental QALY, and Incremental Cost-Effectiveness Ratio (ICER) were calculated. The Willingness-to-Pay (WTP) threshold was considered to be 3 times the Gross Domestic Product (GDP) per capita in China in 2022, $38223 per QALY.
Results
The base-case result is described in Table 2. Compared with no screening, breast cancer screening for average-risk women yielded lower QALYs with higher cost which was absolutely dominated, indicating that screening should focus on high-risk women rather than average-risk ones. Our result was consistent with a previous study that evaluated the economics of mammographic screening for women in rural China [7].
Discussion
Breast cancer is usually diagnosed at an advanced stage with a poorer survival rate because people in the early stage usually remain asymptomatic. Mammography is now the most promising tool for breast cancer screening [1,2]. According to a previous study, breast cancer screening was cost-effective compared with no screening for specific high-risk populations [4]. However, it was not recommended for average-risk women according to our study.
In our study, the Markov model consisting of natural history and post-diagnosis was adopted to simulate the screening programme as performed by the previous study about cancer screening [4,7,16-18]. In natural history, the average-risk population without breast cancer first transited to DCIS or stage I, followed by remaining or progressing to a higher stage. After diagnosis, the stage-specific breast cancer mortality rate was calculated based on SEER Program data. In addition, the distribution characteristic of BI-RADS was considered clearly and used to calculate the proportion of repeating mammography in 24 months or directed biopsy. We also assumed that a biopsy should be done for 50 percent of those with BI-RADS 0 and III. Moreover, similar to previous research, a little decrement in quality of life from false positives was assumed in our study.
Several important limitations still existed in our study. First, we just did a simple cost-effectiveness analysis. Uncertain analysis such as one-way and probability sensitivity analysis should also be done in the future to ensure the robustness of the results. Second, perfect attendance and perfect adherence to screening were assumed in our analysis. However, screening focused on the asymptomatic population, some people may decide not to seek medical treatment if they were still asymptomatic which also influenced the result. Finally, further research is required to estimate the heterogeneity of screening effects for the reason that the screening benefits and the cost-effectiveness of mammography screening may be varied for populations with different characteristics. However, compared with no screening, mammography screening for average-risk women aged 45-69 every two years was absolutely dominated in China.
Conclusion
In conclusion, we should pay more attention to high-risk women if screening and should also ensure prompt diagnosis and treatment of symptomatic women at an early stage at the same time.
- He J, Chen W, Li N, Shen H, Li J, Wang Y. China Guideline for the Screening and Early Detection of Female Breast Cancer (2021, Beijing). China Cancer. 2021; 30(03):161-91.
- Shen S, Sun Q, Huang X, Li Y, Li Y, Niu Z. Breast cancer screening guideline for Chinese women (version 2022). Chinese Research Hospitals. 2022; 9(02):6-13. doi: 10.19450/j.cnki.jcrh.2022.02.003.
- The Society of Breast Cancer, China Anti-Cancer Association. Screening and early diagnosis of breast cancer in China: a practice guideline. China Oncology. 2022; 32(04):363-72. doi: 10.19401/j.cnki.1007-3639.2022.04.010.
- Sun L, Legood R, Sadique Z, Dos-Santos-Silva I, Yang L. Cost-effectiveness of risk-based breast cancer screening programme, China. Bull World Health Organ. 2018 Aug 1;96(8):568-577. doi: 10.2471/BLT.18.207944. Epub 2018 Jun 28. PMID: 30104797; PMCID: PMC6083393.
- American College of Radiology, BI-RADS Fifth Edition 2013.
- National Cancer Center, Disease Prevention and Control Bureau Ministry of Health. Chinese Cancer Registry Annual Report.
- Sun L, Sadique Z, Dos-Santos-Silva I, Yang L, Legood R. Cost-effectiveness of breast cancer screening programme for women in rural China. Int J Cancer. 2019 May 15;144(10):2596-2604. doi: 10.1002/ijc.31956. Epub 2018 Dec 8. PMID: 30367451.
- Myers ER, McCrory DC, Nanda K, Bastian L, Matchar DB. Mathematical model for the natural history of human papillomavirus infection and cervical carcinogenesis. Am J Epidemiol. 2000 Jun 15;151(12):1158-71. doi: 10.1093/oxfordjournals.aje.a010166. PMID: 10905528.
- SEER Program. Division of Cancer Prevention and Control SP, Cancer Statistics Branched [Internet]. Bethesda: National Cancer Institute; 2002. https://seer.cancer.gov/.
- Sun L, Legood R, Yang L. Economic evaluation of ultrasonography and mammography for breast cancer screening among women in China. Chinese Journal of Health Policy. 2017; 10(04):42-50.
- Wu L, Chen G, Ma Y, Li T, Xia J, Liu G. Analysis of breast cancer screening status among women aged 35-64 years in Guangdong Province in 2021. Chinese Journal of Woman and Child Health Research. 2023; 34(07):51-8.
- Two cancers’ screening for rural women Project Management plan. Beijing: National Health and Family Planning Commission of the People’s Republic of China, 2015.
- Zhang X. Screening Analysis and Health Economics Evaluation of Female Breast Cancer in Hebei Province [Master] 2021.
- Gao Y. Development and Health Economic Evaluation of Breast Cancer Screening Strategy among Chinese Women [Doctor] 2016.
- Kolb TM, Lichy J, Newhouse JH. Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27,825 patient evaluations. Radiology. 2002 Oct;225(1):165-75. doi: 10.1148/radiol.2251011667. PMID: 12355001.
- Hofer F, Kauczor HU, Stargardt T. Cost-utility analysis of a potential lung cancer screening program for a high-risk population in Germany: A modelling approach. Lung Cancer. 2018 Oct;124:189-198. doi: 10.1016/j.lungcan.2018.07.036. Epub 2018 Jul 24. PMID: 30268459.
- Griffin E, Hyde C, Long L, Varley-Campbell J, Coelho H, Robinson S, Snowsill T. Lung cancer screening by low-dose computed tomography: a cost-effectiveness analysis of alternative programmes in the UK using a newly developed natural history-based economic model. Diagn Progn Res. 2020 Dec 2;4(1):20. doi: 10.1186/s41512-020-00087-y. PMID: 33292800; PMCID: PMC7709236.
- Zhang T, Chen X, Li C, Wen X, Lin T, Huang J, He J, Zhong N, Jiang J, Liang W. Cost-Effectiveness Analysis of Risk Factor-Based Lung Cancer Screening Program by Low-Dose Computer Tomography in Current Smokers in China. Cancers (Basel). 2023 Sep 6;15(18):4445. doi: 10.3390/cancers15184445. PMID: 37760416; PMCID: PMC10527380.
2China Resources Sanjiu Medical & Pharmaceutical Co. Ltd, Shenzhen, China
Cite this as
Chen X (2023) Cost-effectiveness analysis of breast cancer screening by mammography in average-risk women in China. Adv Women’s Health. 1(1): 001-004. DOI: 10.17352/awh.000001Copyright Licence
© 2023 Chen X. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Breast cancer is the most common form of cancer among women worldwide and is often at an advanced stage when clinical diagnosis. Fortunately, mammography could increase the detection rate of early-stage breast cancer. In this study, we conducted a cost-effectiveness analysis of breast cancer screening compared with no screening for average-risk women aged 45-69 every two years in China. Parameters about screening, costs, and utilities were taken from previous studies. Compared with no screening, mammography screening cost $1566.12 more with a reduction of 0.0088 Quality-Adjusted Life Years (QALYs), which was absolutely dominated. In summary, breast cancer screening by mammography was more recommended to high-risk women rather than average-risk women in China.
Introduction
Breast cancer is a continuing major global public health concern for all women. As a result, breast cancer screening was recommended for high-risk women aged 40 to 69 every year and for average-risk women aged 45 to 69 every 2 years according to China Guideline for the Screening and Early Detection of Female Breast Cancer [1]. Current methods of screening involve clinical breast examination, mammography, ultrasonic examination as well as Magnetic Resonance Imaging (MRI), during which mammography was the most recommended according to clinical practice guidelines [2,3]. Previous study in China has shown that compared with no screening, annual screening for high-risk women is cost-effective [4]. However, further exploration is needed for average-risk women. In this study, we aimed to develop a Markov model to evaluate the cost-effectiveness of breast cancer screening by mammography for average-risk women in China. The time horizon was 45 years (from 40 to 85 years) and the cycle length was one year.
Methods
We compared the current recommended strategy for average-risk women with no screening. The screening process is shown in Figure 1. Breast Imaging Reporting and Data System (BI-RADS) I and II represent negative results. BI-RADS IV and V represent positive results, and BI-RADS 0 and III represent insufficient and suspicious results [5]. Those with positive results, and insufficient or suspicious results will undergo a biopsy, others repeat screening 2 years later.
A Markov model was developed using TreeAge software as shown in Figure 2. The model consisted of twelve states. Women who develop breast cancer could remain in the current stage, progress to a higher stage, be diagnosed by symptoms or screening, or expire due to breast cancer or other cause. The age-specific invasive breast cancer incidence was taken from the Chinese Cancer Registry Annual Report [6]. The transition probability of natural history was obtained from previous studies [4,7,8]. After diagnosis, stage-specific mortality rates were estimated from Surveillance, Epidemiology and End Results (SEER) Program data [9,10].
The effectiveness of screening came from a system review which included 56 studies [1]. The distribution characteristic of BI-RADS was from a breast cancer screening in Guangdong province in 2021 [11].
The cost of screening was taken from the rural breast cancer screening programme, during which the cost of mammography and biopsy were $29.75 and $23.80, respectively [7,12 ]. Moreover, we derived the treatment cost from the Urban Cancer Early Detection and Treatment Program in Hebei province [13].
The utility was extracted from a previous study and we assumed that those with Ductal Carcinoma in Situ (DCIS) have the same utility as those without breast cancer [14,15]. A disutility lasted for 3 months for false positive was also assumed in our model.
Cost and QALYs would be discounted by 5% per year. A half-cycle correction was also applied. The key input parameters are presented in Table 1. Finally, the incremental cost, incremental QALY, and Incremental Cost-Effectiveness Ratio (ICER) were calculated. The Willingness-to-Pay (WTP) threshold was considered to be 3 times the Gross Domestic Product (GDP) per capita in China in 2022, $38223 per QALY.
Results
The base-case result is described in Table 2. Compared with no screening, breast cancer screening for average-risk women yielded lower QALYs with higher cost which was absolutely dominated, indicating that screening should focus on high-risk women rather than average-risk ones. Our result was consistent with a previous study that evaluated the economics of mammographic screening for women in rural China [7].
Discussion
Breast cancer is usually diagnosed at an advanced stage with a poorer survival rate because people in the early stage usually remain asymptomatic. Mammography is now the most promising tool for breast cancer screening [1,2]. According to a previous study, breast cancer screening was cost-effective compared with no screening for specific high-risk populations [4]. However, it was not recommended for average-risk women according to our study.
In our study, the Markov model consisting of natural history and post-diagnosis was adopted to simulate the screening programme as performed by the previous study about cancer screening [4,7,16-18]. In natural history, the average-risk population without breast cancer first transited to DCIS or stage I, followed by remaining or progressing to a higher stage. After diagnosis, the stage-specific breast cancer mortality rate was calculated based on SEER Program data. In addition, the distribution characteristic of BI-RADS was considered clearly and used to calculate the proportion of repeating mammography in 24 months or directed biopsy. We also assumed that a biopsy should be done for 50 percent of those with BI-RADS 0 and III. Moreover, similar to previous research, a little decrement in quality of life from false positives was assumed in our study.
Several important limitations still existed in our study. First, we just did a simple cost-effectiveness analysis. Uncertain analysis such as one-way and probability sensitivity analysis should also be done in the future to ensure the robustness of the results. Second, perfect attendance and perfect adherence to screening were assumed in our analysis. However, screening focused on the asymptomatic population, some people may decide not to seek medical treatment if they were still asymptomatic which also influenced the result. Finally, further research is required to estimate the heterogeneity of screening effects for the reason that the screening benefits and the cost-effectiveness of mammography screening may be varied for populations with different characteristics. However, compared with no screening, mammography screening for average-risk women aged 45-69 every two years was absolutely dominated in China.
Conclusion
In conclusion, we should pay more attention to high-risk women if screening and should also ensure prompt diagnosis and treatment of symptomatic women at an early stage at the same time.
- He J, Chen W, Li N, Shen H, Li J, Wang Y. China Guideline for the Screening and Early Detection of Female Breast Cancer (2021, Beijing). China Cancer. 2021; 30(03):161-91.
- Shen S, Sun Q, Huang X, Li Y, Li Y, Niu Z. Breast cancer screening guideline for Chinese women (version 2022). Chinese Research Hospitals. 2022; 9(02):6-13. doi: 10.19450/j.cnki.jcrh.2022.02.003.
- The Society of Breast Cancer, China Anti-Cancer Association. Screening and early diagnosis of breast cancer in China: a practice guideline. China Oncology. 2022; 32(04):363-72. doi: 10.19401/j.cnki.1007-3639.2022.04.010.
- Sun L, Legood R, Sadique Z, Dos-Santos-Silva I, Yang L. Cost-effectiveness of risk-based breast cancer screening programme, China. Bull World Health Organ. 2018 Aug 1;96(8):568-577. doi: 10.2471/BLT.18.207944. Epub 2018 Jun 28. PMID: 30104797; PMCID: PMC6083393.
- American College of Radiology, BI-RADS Fifth Edition 2013.
- National Cancer Center, Disease Prevention and Control Bureau Ministry of Health. Chinese Cancer Registry Annual Report.
- Sun L, Sadique Z, Dos-Santos-Silva I, Yang L, Legood R. Cost-effectiveness of breast cancer screening programme for women in rural China. Int J Cancer. 2019 May 15;144(10):2596-2604. doi: 10.1002/ijc.31956. Epub 2018 Dec 8. PMID: 30367451.
- Myers ER, McCrory DC, Nanda K, Bastian L, Matchar DB. Mathematical model for the natural history of human papillomavirus infection and cervical carcinogenesis. Am J Epidemiol. 2000 Jun 15;151(12):1158-71. doi: 10.1093/oxfordjournals.aje.a010166. PMID: 10905528.
- SEER Program. Division of Cancer Prevention and Control SP, Cancer Statistics Branched [Internet]. Bethesda: National Cancer Institute; 2002. https://seer.cancer.gov/.
- Sun L, Legood R, Yang L. Economic evaluation of ultrasonography and mammography for breast cancer screening among women in China. Chinese Journal of Health Policy. 2017; 10(04):42-50.
- Wu L, Chen G, Ma Y, Li T, Xia J, Liu G. Analysis of breast cancer screening status among women aged 35-64 years in Guangdong Province in 2021. Chinese Journal of Woman and Child Health Research. 2023; 34(07):51-8.
- Two cancers’ screening for rural women Project Management plan. Beijing: National Health and Family Planning Commission of the People’s Republic of China, 2015.
- Zhang X. Screening Analysis and Health Economics Evaluation of Female Breast Cancer in Hebei Province [Master] 2021.
- Gao Y. Development and Health Economic Evaluation of Breast Cancer Screening Strategy among Chinese Women [Doctor] 2016.
- Kolb TM, Lichy J, Newhouse JH. Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27,825 patient evaluations. Radiology. 2002 Oct;225(1):165-75. doi: 10.1148/radiol.2251011667. PMID: 12355001.
- Hofer F, Kauczor HU, Stargardt T. Cost-utility analysis of a potential lung cancer screening program for a high-risk population in Germany: A modelling approach. Lung Cancer. 2018 Oct;124:189-198. doi: 10.1016/j.lungcan.2018.07.036. Epub 2018 Jul 24. PMID: 30268459.
- Griffin E, Hyde C, Long L, Varley-Campbell J, Coelho H, Robinson S, Snowsill T. Lung cancer screening by low-dose computed tomography: a cost-effectiveness analysis of alternative programmes in the UK using a newly developed natural history-based economic model. Diagn Progn Res. 2020 Dec 2;4(1):20. doi: 10.1186/s41512-020-00087-y. PMID: 33292800; PMCID: PMC7709236.
- Zhang T, Chen X, Li C, Wen X, Lin T, Huang J, He J, Zhong N, Jiang J, Liang W. Cost-Effectiveness Analysis of Risk Factor-Based Lung Cancer Screening Program by Low-Dose Computer Tomography in Current Smokers in China. Cancers (Basel). 2023 Sep 6;15(18):4445. doi: 10.3390/cancers15184445. PMID: 37760416; PMCID: PMC10527380.
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