Personalizing Mammography by Breast Density and Other Risk Factorsfor Breast Cancer: Analysis of Health Beneﬁts and Cost-Effectiveness
Current guidelines recommend mammography every1 or 2 years starting at age 40 or 50 years, regardless of individualrisk for breast cancer.
To estimate the cost-effectiveness of mammography byage, breast density, history of breast biopsy, family history of breastcancer, and screening interval.
Markov microsimulation model.
Surveillance, Epidemiology, and End Results program,Breast Cancer Surveillance Consortium, and the medical literature.
U.S. women aged 40 to 49, 50 to 59, 60 to69, and 70 to 79 years with initial mammography at age 40 yearsand breast density of Breast Imaging Reporting and Data System(BI-RADS) categories 1 to 4.
National health payer.
Mammography annually, biennially, or every 3 to 4years or no mammography.
Costs per quality-adjusted life-year (QALY)gained and number of women screened over 10 years to prevent 1death from breast cancer.
Biennial mammography cost lessthan $100 000 per QALY gained for women aged 40 to 79 yearswith BI-RADS category 3 or 4 breast density or aged 50 to 69 yearswith category 2 density; women aged 60 to 79 years with category1 density and either a family history of breast cancer or a previousbreast biopsy; and all women aged 40 to 79 years with both afamily history of breast cancer and a previous breast biopsy, re-gardless of breast density. Biennial mammography cost less than$50 000 per QALY gained for women aged 40 to 49 years withcategory 3 or 4 breast density and either a previous breast biopsyor a family history of breast cancer. Annual mammography was notcost-effective for any group, regardless of age or breast density.
Mammography is expensive if thedisutility of false-positive mammography results and the costs of de-tecting nonprogressive and nonlethal invasive cancer are considered.
Results are not applicable to carriers of
Mammography screening should be personalized onthe basis of a woman’s age, breast density, history of breast biopsy,family history of breast cancer, and beliefs about the potentialbenefit and harms of screening.
Eli Lilly, Da Costa Family Foundation for Research in Breast Cancer Prevention of the California Pacific Med-ical Center, and Breast Cancer Surveillance Consortium.
Ann Intern Med.
For author affiliations, see end of text.
Using screening mammography to detect early-stage invasivebreast cancer reduces breast cancer mortality by 15% to 25%(1–6) and is cost-effective for women at average risk for breastcancer (7–13). However, the frequency with which womenshould receive mammography is controversial. Some guide-lines recommend mammography every 1 to 2 years for all women aged 40 years or older (14, 15). The U.S. PreventiveServices Task Force (USPSTF) recently issued guidelines rec-ommending that mammography be done biennially for women aged 50 to 74 years, but not routinely for womenyounger than 50 years (16).These guidelines do not consider the inﬂuence of com-mon risk factors for breast cancer other than age. Breastcancer risk is strongly associated with breast density (17–19), with low breast density (Breast Imaging Reportingand Data System [BI-RADS] category 1) associated withless-than-average risk and high breast density (categories 3and 4) with higher-than-average risk (20). Family history of breast cancer and a previous breast biopsy are also risk factors for breast cancer (20). The health beneﬁts and costutility of screening mammography may be strongly inﬂu-enced by a woman’s risk for breast cancer, which can beestimated from her age, breast density on an initial mam-mogram (20, 21), history of breast biopsy, and family his-tory of breast cancer (20). Our objective was to examinethe health beneﬁts and cost utility of mammography per-formed every 3 to 4 years, biennially, or annually in women with different proﬁles of breast cancer risk.
Our analysis was based on data from women in theUnited States and assumed the perspective of a national health
Editors’ Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Editorial comment. . . . . . . . . . . . . . . . . . . . . . . . . . . 58
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© 2011 American College of Physicians