RT radiation br Probabilistic CEA br Probabilistic
Probabilistic analysis from 100 repeated simulations is summa-rized as the CEacc frontier (Fig. 3). Many screening strategies never reached the CEacc frontier. Of those that are potentially the optimal screening strategies, Figure 3 shows that the updated USPSTF/AAFP/ACP recommendations (specifically, biennial screening between the ages of 50 and 75 years) are most likely optimal when the societal willingness to pay is in the range of $40,500/QALY to $44,000/QALY. The updated ACS guideline has the highest probability of being optimal when the societal will-ingness to pay is between $44,000/QALY and $103,500/QALY. Screening strategies involving annual screening intervals starting at the age of 40 years, as recommended by the 2003 ACS guideline and the current ACR and ACOG guidelines, are desirable only when the societal willingness to pay exceeds $103,500/QALY. Figure 2 also shows that within the wide range of societal will-ingness to pay explored in this study, no optimal strategy involves screening with cessation at the age of 80 years or without upper age limits.
This study used a microsimulation model integrated with medical cost data that reflected real-world breast cancer treatment patterns to assess the cost-effectiveness of two recently updated breast cancer screening guidelines, the USPSTF and ACS guidelines, respectively, and screening strategies in the ACOG and ACR guidelines. Our findings show that screening strategies conforming
to the updated ACS guideline are most likely to be cost-effective within the range of the societal willingness to pay ($50,000e$100,000/QALY) considered acceptable in the United States [55,56]. We also find that a population-based breast cancer screening program that continues screening past the age of 80 years for all women at an average risk of developing breast cancer is not cost-effective, regardless of screening intervals or 4μ8C age.
Breast cancer remains one of the most devastating diseases for women. Although women want to guard against breast cancer through early detection from screening, as the American health care system moves toward value-based medicine, it becomes increasingly important to understand the harm-benefit trade-off of various breast cancer screening strategies. This challenge was explored in studies published by the Cancer Intervention and Surveillance Modeling Network (CISNET) [57,58]. Their recent publication used six simulation models to compare the benefits and harms of eight screening strategies, covering three starting ages (40, 45, or 50 years) in combination with annual, biennial, or a hybrid interval reproductive system transitioned from annual screening in the 40s to biennial screening at the age of 50 years, all with the same cessation age of 74 years . The authors concluded that biennial strategies were the most efficient for average-risk women without further differentiating among strategies at different starting ages, because all three strategies were on the frontier of efficiency in the frontier plot . Although the efficiency frontier is an informative way to illustrate the harm-benefit trade-offs because strategies not on the frontier were considered inefficient, selecting the optimal strategy from those remaining on the frontier is chal-lenging because metrics such as life-years gained per additional
Table 3 – Costs and QALYs of breast cancer screening strategies, discounted at 3%.
Strategy, age (y) Notation Costs (vs. no screening) QALYs (vs. no screening)
Updated USPSTF/AAFP/ACP breast cancer screening guidelines
Updated ACS breast cancer screening guidelines
Previous ACS/ACOG/ACR breast cancer screening guidelines
AAFP, American Association of Family Physicians; ACOG, American Congress of Obstetricians and Gynecologists; ACP, American College of Physicians; ACR, American College of Radiology; ACS, American Cancer Society; QALY, quality-adjusted life-year; USPSTF, US Preventive Services Task Force.
Fig. 2 – Cost-Effectiveness Plane of 10 Breast Cancer Screening Strategies. Abbreviations: ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life-year.
mammography performed are difficult to decipher for decision makers facing budgetary constraints. By summarizing harm-benefit trade-offs in terms of cost per QALY gained, CEA offers a more transparent way to relate the harm-benefit trade-off to cost-conscious stakeholders. This exploration allows us to conclude from our model that biennial strategies considered to be efficient in the CISNET models would most likely be cost-effective only within a rather narrow range of societal willingness to pay ($40,500e$44,000/QALY).