Cost-Effectiveness of Digital Mammography Breast Cancer Screening

Cost-Effectiveness of Digital Mammography Breast Cancer Screening

Anna N.A. Tosteson, ScD;
Natasha K. Stout, PhD;
Dennis G. Fryback, PhD;
Suddhasatta Acharyya, PhD;
Benjamin A. Herman, SM;
Lucy G. Hannah, MS, MAT;
Etta D. Pisano, MD; and
for the DMIST Investigators*

From The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Lebanon, New Hampshire; Harvard School of Public Health, Boston, Massachusetts; University of Wisconsin, Madison, Wisconsin; Brown University, Providence, Rhode Island; and University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Abstract

Background: The DMIST (Digital Mammography Imaging Screening Trial) reported improved breast cancer detection with digital mammography compared with film mammography in selected population subgroups, but it did not assess the economic value of digital relative to film mammography screening.

Objective: To evaluate the cost-effectiveness of digital mammography screening for breast cancer.

Design: Validated, discrete-event simulation model.

Data Sources: Data from DMIST and publicly available U.S. data.

Target Population: U.S. women age 40 years or older.

Time Horizon: Lifetime.

Perspective: Societal and Medicare.

Intervention: All-film mammography screening; all-digital mammography screening; and targeted digital mammography screening, which is age-targeted digital mammography (for women <50 years of age) and age- and density-targeted digital mammography (for women <50 years of age or women ≥50 years of age with dense breasts).

Outcome Measures: Cost per quality-adjusted life-year (QALY) gained.

Results of Base-Case Analysis: All-digital mammography screening cost $331 000 (95% CI, $268 000 to $403 000) per QALY gained relative to all-film mammography screening but was more costly and less effective than targeted digital mammography screening. Targeted digital mammography screening resulted in more screen-detected cases of cancer and fewer deaths from cancer than either all-film or all-digital mammography screening, with cost-effectiveness estimates ranging from $26 500 (CI, $21 000 to $33 000) per QALY gained for age-targeted digital mammography to $84 500 (CI, $75 000 to $93 000) per QALY gained for age- and density-targeted digital mammography. In the Medicare population, the cost-effectiveness of density-targeted digital mammography screening varied from a base-case estimate of $97 000 (CI, $77 000 to $131 000) to $257 000 per QALY gained (CI, $91 000 to $536 000) in the alternative-case analyses, in which the sensitivity of film mammography was increased and the sensitivity of digital mammography in women with nondense breasts was decreased.

Results of Sensitivity Analysis: Results were sensitive to the cost of digital mammography and to the prevalence of dense breasts.

Limitations: Results were dependent on model assumptions and DMIST findings.

Conclusion: Relative to film mammography, screening for breast cancer by using all-digital mammography is not cost-effective. Age-targeted screening with digital mammography seems cost-effective, whereas density-targeted screening strategies are more costly and of uncertain value, particularly among women age 65 years or older.

Article and Author Information

Grant Support: By National Cancer Institute grants CA80098, CA79778, and CA88211.
Potential Financial Conflicts of Interest: Consultancies: D.G. Fryback (Dartmouth College). Grants received: D.G. Fryback (ACRIN). Institutional: D.G. Fryback (University of Wisconsin, which offers digital mammography services); E.D. Pisano (University of North Carolina, which receives research support from GE).
Reproducible Research Statement: DMIST contact personnel: http://www.acrin.org/PROTOCOLSUMMARYTABLE/PROTOCOL6652/6652ContactPersonnel/tabid/393/Default.aspx. Study protocol: Partial protocol (with information on how to obtain the full protocol) is available at http://www.acrin.org/Portals/0/Protocols/6652/A6652partial_summary.pdf. Statistical code and data set: Available with restriction in accordance with the ACRIN data-sharing policies at http://www.acrin.org/RESEARCHERS/POLICIES/DATAANDIMAGESHARINGPOLICY/DATAACCESSPOLICYDOCUMENT/tabid/475/Default.aspx.
Requests for Single Reprints: Anna N.A. Tosteson, ScD, Clinical Research HB7505, Dartmouth Medical School, One Medical Center Drive, Lebanon, NH 03756; e-mail, anna.tosteson{at}dartmouth.edu.
Current Author Addresses: Dr. Tosteson: Dartmouth Medical School, One Medical Center Drive, Lebanon, NH 03756.
Dr. Stout: Program in Health Decision Science, Department of Health Policy and Management, 718 Huntington Avenue, Harvard School of Public Health, Boston, MA 02115.
Dr. Fryback: Departments of Population Health Sciences and of Industrial and Systems Engineering, University of Wisconsin, 610 Walnut Street, Room 685, Madison, WI 53726.
Dr. Acharyya, Mr. Herman, and Ms. Hannah: Statistical Sciences Center, Brown University, Box G-121-7, 121 South Main Street, Providence, RI 02912.
Dr. Pisano: Department of Radiology and Biomedical Engineering of the Lineberger Comprehensive Cancer Center and Biomedical Research Imaging Center, CB700, 4th Floor, Bondurant Hall, Dean's Office, University of North Carolina School of Medicine, Chapel Hill, NC 27599.
Author Contributions: Conception and design: A.N.A. Tosteson, D.G. Fryback, E.D. Pisano.
Analysis and interpretation of the data: A.N.A. Tosteson, N.K. Stout, D.G. Fryback, S. Acharyya, B.A. Herman, L. Hannah, E.D. Pisano.
Drafting of the article: A.N.A. Tosteson, N.K. Stout, D.G. Fryback, S. Acharyya, B.A. Herman.
Critical revision of the article for important intellectual content: A.N.A. Tosteson, N.K. Stout, D.G. Fryback, S. Acharyya, B.A. Herman, E.D. Pisano.
Final approval of the article: A.N.A. Tosteson, N.K. Stout, D.G. Fryback, S. Acharyya, B.A. Herman, L. Hannah, E.D. Pisano.
Provision of study materials or patients: E.T. Pisano.
Statistical expertise: A.N.A. Tosteson, D.G. Fryback, S. Acharyya, B.A. Herman, L. Hannah.
Obtaining of funding: A.N.A. Tosteson, E.D. Pisano.
Administrative, technical, or logistic support: A.N.A. Tosteson, N.K. Stout, D.G. Fryback, B.A. Herman.
Collection and assembly of data: B.A. Herman, L. Hannah.
↵* For a list of the DMIST clinical sites, principal investigators, and lead physicists, see the Appendix.