Cost-Effectiveness of Mammography, MRI, and Ultrasonography for Breast Cancer Screening
Section snippets
Screening mammography
The cost per cancer detected is always lower in older populations, because screening detection rates parallel the natural cancer incidence, thus increasing with age. The cost per life saved and cost per year of life expectancy gained progressively decreases from age 40 years until age 70 years but then increases as a result of the lower normal life expectancy among older women. Assuming a 30% reduction in breast cancer mortality through annual screening mammography, Rosenquist and Lindfors8
Costs of screening recall and biopsy
In a low-cost screening project in Southern California in 1986 reported by Cyrlak,21 the costs of screening mammograms accounted for less than one-third of total screening program costs, with diagnostic imaging workups, surgical consultations, and biopsies for benign disease representing the major induced costs of screening. In this study, 18% of women were recalled from screening for additional imaging workup or clinical evaluation. Among 72 biopsied patients, only 12 were found to have
Screening mammography results, guidelines, and controversies: role of cost-effectiveness
Screening controversies have been recurrent since 1975, when screening began to be widely used in the United States. With long-term follow-up, screening trials have demonstrated convincingly greater proof of benefit. Since 1997, annual screening for all women aged 40 years and older has been recommended by the American Cancer Society (ACS) and the ACR.43, 44 Currently, about 51% of all women in this age group report that they have had a mammogram in the past year and 67%, in the past 2 years.45
Magnetic resonance imaging screening of very high-risk women: results and guidelines
Unlike mammography, no randomized trial has ever been conducted to evaluate whether magnetic resonance imaging (MRI) screening can reduce breast cancer mortality. However, since 2004, 9 nonoverlapping series with a total of 4485 very high-risk women screened with mammography and MRI found that 36% (70 of 192) of cancers were detected by mammography and an additional 56% (108 of 192) were identified only by MRI for a combined screening sensitivity of 92.7% (4157 of 4485).63, 64, 65, 66, 67, 68,
MRI screening of very high-risk women: cost-effectiveness
Several studies have evaluated the cost-effectiveness of screening MRI. Plevritis and colleagues76 estimated that the cost per quality-adjusted life year (QALY) for annual screening with mammography and MRI relative to screening with mammography alone between ages 35 and 54 years was $55,420 for women with a BRCA1 mutation and $130,695, for BRCA2. For women with dense breasts, estimated cost per QALY was $41,183 for BRCA1 carriers and $98,454 for BRCA2. Higher cancer rates and more aggressive
MRI screening of moderately high-risk women: cost-effectiveness
Using results from the Magnetic Resonance Imaging Breast Screening Study (MARIBS) conducted in the UK, Griebsch and colleagues78 found that the incremental cost of adding MRI screening to mammographic screening for women having a 50% likelihood of BRCA1 or 2 was $50,911 per cancer detected. For known mutation carriers, the cost was $27,544 per cancer detected. A further analysis of the UK MRI screening data found that the incremental cost of screening 40- to 49-year-old women with mammography
Impact of risk assessment models and future technical advances on cost-effectiveness of MRI screening
Because the cost of MRI is more than $1000 compared with about $100 for mammography, accurate determination of individual breast cancer risk is essential for a cost-effective MRI screening program. By age 70 years, the lifetime risk of breast cancer is 65% for BRCA1 carriers and 45% for BRCA2 carriers81 compared with a cumulative lifetime risk of 12% by age 80 years for a woman with no known risk factors.82 All current risk models are inaccurate for predicting breast cancer risk for the vast
Screening ultrasonography: target populations
Among the 9 series of very high-risk women screened with MRI and mammography, 4 also included ultrasonography. These 4 series found that the sensitivity of mammography and ultrasonography combined was only 52%, compared with a 92.7% sensitivity for mammography and MRI combined.64, 67, 68, 69 This observation that the sensitivity of MRI is much higher than that of ultrasonography is substantiated by the clinical experience that most MRI-detected cancers cannot be localized for ultrasound-guided
Nonblinded ultrasonographic screening trials
Between 1995 and 2003, 42,836 women with generally dense breast tissue were screened with mammography and ultrasonography using hand-held high-resolution transducers (7.5–10.0 MHz) in 6 published series.103, 104, 105, 106, 107, 108, 109, 110 Interpretations were nonblinded to those of the other modality. A review of these studies by Feig111 found that cancer detection rates with ultrasonography alone ranged from 2.7 to 9.0 per 1000 (mean = 3.5 per 1000). Mean tumor size was 1.0 cm for
Blinded ultrasonographic screening trials
Because nonblinded studies may be subject to reader bias, the ACR Imaging Network (ACRIN) initiated ACRIN Trial 6666 to determine if results from the prior 6 nonblinded ultrasonographic screening studies could be duplicated under a more scientifically rigorous protocol. Radiologist readers of mammography and ultrasonography were each masked to results from the other modality. Following initial screening of 2809 very high-risk women having dense breasts, Berg and colleagues114 diagnosed 41
Automated ultrasonographic screening
The length of time for the US screening examination is another limitation and was clocked at 19 minutes in the ACRIN trial, moderately higher than the estimated examination times in other studies of ultrasonographic screening performed using hand-held transducers. Thus, total radiologist time for performance, interpretation, and report dictation for ultrasonographic screening could be 25 to 30 minutes. By comparison, the time for interpretation of screening mammography was measured as 5 minutes
Summary
Screening mammography performed annually on all women beginning at age 40 years has reduced breast cancer deaths by 30% to 50%. The cost per year of life saved is well within the range for other commonly accepted medical interventions. Various studies have estimated that reduction in treatment costs through early screening detection may be 30% to 100% or more of the cost of screening. MRI screening is also cost-effective for very high-risk women, such as BRCA carriers, and others at 20% or
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