Cost-effectiveness of breast cancer screening

Screening for breast cancer by mammography has been an essential element in reducing mortality.¹ Nevertheless, mammography is less sensitive in women with extremely dense breast tissue.² Thanks largely to the DENSE study, which showed that screening with an abbreviated MRI protocol every 4 years is cost effective,³ abbreviated MRI can be considered as a supplemental tool for breast cancer screening.²

Limitations of mammographic screening

Mammographic screening for early detection of breast cancer has contributed to a 40% relative reduction in mortality in women aged between 40 and 74 years.^4,5 Regular mammographic screening has been shown to reduce mortality by 23% in the women invited for screening.⁶ However, mammography alone is not sufficient for screening women at higher than average risk of developing breast cancer, particularly for women with high breast density where the technique has limited sensitivity.^1-3 Due to the relatively high cost and limited accessibility, screening with MRI has traditionally only be used in women at high risk of breast cancer as a supplement to mammographic screening.²

The DENSE study

Recently, the randomized, multicenter Dense Tissue and Early Breast Neoplasm Screening (DENSE) trial showed that additional MRI screening for women with extremely dense breast tissue resulted in significantly fewer interval cancers.³ Screen-detected tumors were smaller on average among MRI participants than in those in women receiving mammography alone.³ Using screening with MRI alone every 4 years resulted in the highest acceptable incremental cost effectiveness ratio (ICER) when applying the NICE threshold.³ Based on these results, screening with MRI alone every 4 years would be recommended from a cost-effectiveness perspective.³

 When women know they have very dense breasts and thus an elevated breast cancer risk, they may want to be screened more than once every 4 years. The authors suggest that when a 2-year interval is preferred by policy makers, alternating mammography and MRI could be a solution.³

In the cost-effectiveness analysis of the DENSE study, the unit cost of MRI was calculated to be €272, and the ICER was highly sensitive to this. Developments in the near future such as artificial intelligence and abbreviated MRI, which could reduce false-positive diagnoses as well as acquisition and reading time, can be expected to bring down the costs of individual MRI screening.³

Abbreviated MRI

Abbreviated breast MRI has been shown to reduce both examination and image reading times and to improve cost-effectiveness of breast cancer screening.⁷ Some studies have reported shorter acquisition and interpretation times with an abbreviated protocol compared with a standard protocol with similar cancer detection rates; other studies have shown shortened interpretation times with equivalent sensitivities and specificities for cancer detection with abbreviated protocols.¹

These shorter acquisition times may improve patient comfort and potentially also increase compliance, making abbreviated MRI a viable option for screening from the patient perspective.¹

In terms of cost reductions, as time the magnet is running is reduced, MRI operating costs are lower with abbreviated protocols. More patients can also be scheduled per day, increasing access to the MRI and reducing staffing costs per patient.¹ These potential cost reductions with abbreviated MRI protocols in breast cancer screening may become quite substantial when applied at the population level.⁷

Key points

• With the development of the abbreviated MRI protocol, MRI is both feasible and cost-effective for the screening of women with dense breasts as an alternative to mammography from age 50-65, but it is not an option for women with heterogeneously dense breasts²
• Abbreviated MRI in the diagnostic setting can reduce healthcare costs and disparities by increasing access to breast MRI¹

^*National Institute for Health and Care Excellence

References

1. Wahab RA, Albasha H, Martin J, Lee SJ, Zhang B, Brown AL, Vijapura C, Lewis K, Sobel LD, Mahoney MC. Characterization of common breast MRI abnormalities: comparison between abbreviated and full MRI protocols. Clin Imaging 2021;79:125-32.
2. Wang J, Greuter MJW, Vermeulen KM, Brokken FB, Dorrius MD, Lu W, de Bock GH. Cost-effectiveness of abbreviated-protocol MRI screening for women with mammographically dense breasts in a national breast cancer screening program. Breast 2022;61:58-65.
3. Geuzinge HA, Bakker MF, Heijnsdijk EAM, van Ravesteyn NT, Veldhuis WB, Pijnappel RM, de Lange SV, Emaus MJ, Mann RM, Monninkhof EM, de Koekkoek-Doll PK, van Gils CH, de Koning HJ. Cost-effectiveness of magnetic resonance imaging screening for women With extremely dense breast tissue. J Natl Cancer Inst 2021;113:1476-83.
4. Oeffinger KC, Fontham ET, Etzioni R, Herzig A, Michaelson JS, Shih YC, Walter LC, Church TR, Flowers CR, LaMonte SJ, Wolf AM, DeSantis C, Lortet-Tieulent J, Andrews K, Manassaram-Baptiste D, Saslow D, Smith RA, Brawley OW, Wender R. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. Jama 2015;314:1599-614.
5. Tabar L, Yen MF, Vitak B, Chen HH, Smith RA, Duffy SW. Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening. Lancet 2003;361:1405-10.
6. Lauby-Secretan B, Scoccianti C, Loomis D, Benbrahim-Tallaa L, Bouvard V, Bianchini F, Straif K. Breast-cancer screening--viewpoint of the IARC Working Group. N Engl J Med 2015;372:2353-8.
7. Tollens F, Baltzer PAT, Dietzel M, Schnitzer ML, Schwarze V, Kunz WG, Rink J, Rübenthaler J, Froelich MF, Schönberg SO, Kaiser CG. Economic potential of abbreviated breast MRI for screening women with dense breast tissue for breast cancer. Eur Radiol 2022.