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Risk-stratified breast cancer screening more cost-effective than age-based method
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Not screening women at lower risk for breast cancer could make screening programs more cost-effective and reduce overdiagnosis, according to data from a life-table model from researchers in the U.K.
Screening recommendations for breast cancer based on age fail to account for individual variation in risk.
“Screening for breast cancer reduces deaths from the cancer. However, the trade-offs include overdiagnosis and overtreatment,” Nora Pashayan, MD, PhD, clinical reader in applied health researcher at University College London, and colleagues wrote.
“Risk-stratified screening would require assessing risk of all women, which would entail additional costs,” they added. “However, these may be offset by eliminating repeated screening of women at lower risk and avoiding treatment of overdiagnosed cancers.”
Researchers assessed the benefit-to-harm ratio and cost-effectiveness of risk-stratified breast cancer screening programs compared with standard age-based screening and no screening.
They did so by creating a life-table model of 364,500 hypothetical women aged 50 years living in the U.K. with follow-up to age 85 years. Pashayan and colleagues built the model using findings from the Independent U.K. Panel on Breast Cancer Screening, as well as with risk distribution data based on a polygenic risk profile.
Modeled interventions included no screening; age-based screening with mammography every 3 years from age 50 years to 69 years; and risk-based screening, defined as screening all women with a risk score considered greater than that of a threshold risk every 3 years until age 69 years.
The main outcomes included breast cancer deaths averted, overdiagnoses, gains in quality-adjusted life-years, costs and net monetary benefit.
As researchers lowered the risk threshold, screening costs increased linearly, with no quality-adjusted life-years gained after lowering the risk threshold below the 35th percentile.
At a willingness-to-pay benchmark of £20,000 — or $26,800 — for each quality-adjusted life-year gained, the risk-stratified screening program with the risk threshold set to the 70th percentile offered the greatest net monetary benefit. This scenario had a 72% probability of being cost-effective.
Compared with age-based screening, risk-stratified screening at the 32nd vs. 70th percentile risk threshold was projected to cost £20,066 ($26,888) vs. £53,7985 ($72,0900) less, result in 26.7% vs. 71.4% fewer instances of overdiagnosis, and avert 2.9% vs. 9.6% fewer breast cancer deaths.
Implementing a risk-stratified program would produce challenges in the U.S., including cost barriers, organizational issues for storing genomic information, and a lack of knowledge on the part of both patients and physicians, Megan C. Roberts, PhD, cancer prevention fellow at the NCI, wrote in an accompanying editorial.
“These implementation challenges are not meant to discourage the pursuit of precision screening; rather, they point to a remaining need for additional implementation research about precision screening approaches across patient, clinician, and health system levels,” Roberts wrote. “As prevention becomes increasingly more precise, we must address these issues such that the promise of precision screening can be achieved.” – by Andy Polhamus
Disclosures: The authors report no relevant financial disclosures. Roberts reports no relevant disclosures.
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