Evaluation of a Risk-Stratified National Breast Screening Programme in the United Kingdom: An updated cost-effectiveness analysis

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Abstract Study objective To update a published early economic evaluation of exemplar risk-stratified national breast screening programmes (stratified-NBSP). Method An existing validated decision-analytic model, using discrete event simulation (the ‘Gray-model’), was used to structure the pathways for 3 stratified-NBSP (risk-1; risk-2; risk-3) compared with the current NBSP in the United Kingdom (UK-NBSP), biannual screening, and no screening. The updated model is called MANC-RISK-SCREEN and assumes a life-time horizon, the UK health service perspective to identify costs (using £; 2022) and measures health consequences using life-years and Quality Adjusted Life Years (QALYs). The original data sources used for the Gray-model were assessed for current relevance and updated where feasible. Updated data sources included: cancer and all-cause mortality; breast cancer incidence; breast cancer risk data; tumour staging; recall rate; mammographic sensitivity by breast density group; costs; and utilities. Model parameter uncertainty was assessed using Probabilistic Sensitivity Analysis (PSA) and one-way sensitivity analysis. Results The base case analysis, supported by PSA, suggested that there was always a risk-stratified approach to breast cancer screening that was superior to universal screening. In the base case analysis, a strategy of dividing women into three equal groups based on risk was the most cost-effective. In the PSA, a strategy based on that used in the BC-PREDICT study was the most cost-effective. There was uncertainty in whether the addition of reduced screening for women at lower risk was cost-effective. Conclusion The results of this study suggest that risk-stratified approaches to breast cancer screening are more cost-effective than both 3-yearly and 2-yearly universal screening. Highlights A published early decision-analytic model-based cost-effectiveness analysis, using discrete event simulation (the ‘Gray model’), produced indicative results suggesting all included exemplars of a stratified national breast screening programme (stratified-NBSP) were cost-effective compared with no screening but a fully incremental analysis indicated only risk-based stratified-NBSP were cost-effective. This study uses a subsequently validated version of the Gray-model to produce a cost-effectiveness analysis with an updated model called MANC-RISK-SCREEN using revised descriptions of the relevant stratified-NBSP and new values for cancer and all-cause mortality; breast cancer incidence; breast cancer risk data; tumour staging; recall rate; mammographic sensitivity by breast density group; costs; and utilities. This analysis builds on the indicative estimates of the healthcare costs and health consequences of stratified-NBSP and suggests, with the current level of evidence, they are a cost-effective use of the NHS budget in the United Kingdom but uncertainty remains in the value of reducing screening for those at lower risk.

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.