Health Economic Comparison And Prediction Of Mammography- And Ultrasound-based Breast Cancer Screening In Chinese Women

Objective: Breast cancer,as the most common cancer in Chinese women,has brought increasingly burden of disease.Breast cancer screening plays a role on identifying cancers at early stage and decreasing breast cancer mortality in average risk population.Mammography-based screening has been recommended in European and North American countries as a routine examination for women,and its cost-effectiveness has been estimated.However,the performance of mammography is limited in Chinese women whose breast seems much denser than that in Caucasians.Recent studies have reported that breast ultrasound could play a role on breast cancer screening as an alternative method,which has a higher accuracy in dense breast and has lower cost,compared with mammography.This study was aimed to compare the cost-effectiveness,cost-utility and cost-benefit of ultrasound-and mammography-based breast cancer screening and provide evidence related to the economic evaluation on screening programmes in Chinese women.Methods: The Markov models used in the present study for cost-effectiveness analysis of breast cancer screening strategies were developed by using Tree Age Pro software,calibrated to most recent data.The screening strategies included mammography alone(MMG),ultrasound alone(US),mammography after positive ultrasound result(USMMG),ultrasound after positive mammography result(MMG-US)and combination of these two methods(MMG+US).The screening intervals included once,twice and three times per year.By using these models,we simulated a hypothetical cohort of 100,000 asymptomatic women aged 35 years with a 50-year follow-up.We compared the cost-effectiveness/utility ratio which was the cost required for a life-year(LY)and a quality adjusted life years(QALY)and the incremental cost-effectiveness/utility ratio(ICER/ICUR)between strategies compared to a situation without screening.Both effectiveness and costs were discounted at 3% per year.The one-way,two-way sensitivity analysis and a probabilistic sensitivity analysis were conducted to explore the effect of parameter uncertainty on the choice of optimal strategy.Results: A 50-year simulation of 100,000 women aged from 35 years old showed that,compared with the non-breast cancer screening,each screening method had an increased proportion of patients with early breast cancer(from 16.4% to 55.35%),increased expected life expectancy of the screening population(by 0.00373 to 0.00527 years),the increased LY(by 0353 to 512 LY)and QALY(by 179 to 272 QALY).USMMG strategy cost lowest for requiring one QALY of was lowest:167.23,144.45 and 136.65 yuan and 139.66 yuan when the interval was one,two and three years respectively,compared with that of other strategies.US-MMG strategy had the lowest ICUR as 7000 yuan per QALY compared with non-screening strategy,which was less than China’s GDP per capita in 2015(53,900 yuan per QALY).US-MMG strategy also had the highest net monetary benefit as 3.76 million yuan and had an absolute costeffectiveness and cost-benefit advantage over other screening strategies.The influential factors of net monetary benefit of breast cancer screening strategies were as follows: unit cost,unit time,sensitivity and specificity of ultrasound-and mammography-based screening examination,participation rate,starting and ending age of screening,sensitivity and specificity of MMG+US strategy.Except for the specificity of US and unit cost of MMG and US,the remaining factors had no effect on the choice of optimal strategy.Conclusion: This study compared the cost-effectiveness,cost-utility,and cost-benefit indicators of breast mammography and ultrasound applied to breast cancer screening programs and found that US-MMG screening had an absolute cost-effectiveness and cost-benefit advantage over non-screening,US along,MMG along,MMG-US and MMG+US.The specificity of breast ultrasound and unit cost of screening modalities were important uncertainties affecting the health economics.Therefore,the accuracy of breast ultrasound and the unit cost should be controlled in order to improve the stability of screening performance.