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Mammogram Study

Mammogram Study

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Published by: CBS11 on Jul 05, 2011
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Personalizing Mammography by Breast Density and Other Risk Factorsfor Breast Cancer: Analysis of Health Benefits and Cost-Effectiveness
 JohnT.Schousboe,MD,PhD;KarlaKerlikowske,MD,MS;AndrewLoh,BA;andStevenR.Cummings,MD
Background:
Current guidelines recommend mammography every1 or 2 years starting at age 40 or 50 years, regardless of individualrisk for breast cancer.
Objective:
To estimate the cost-effectiveness of mammography byage, breast density, history of breast biopsy, family history of breastcancer, and screening interval.
Design:
Markov microsimulation model.
DataSources:
Surveillance, Epidemiology, and End Results program,Breast Cancer Surveillance Consortium, and the medical literature.
TargetPopulation:
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.
TimeHorizon:
Lifetime.
Perspective:
National health payer.
Intervention:
Mammography annually, biennially, or every 3 to 4years or no mammography.
OutcomeMeasures:
Costs per quality-adjusted life-year (QALY)gained and number of women screened over 10 years to prevent 1death from breast cancer.
ResultsofBase-CaseAnalysis:
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.
ResultsofSensitivityAnalysis:
Mammography is expensive if thedisutility of false-positive mammography results and the costs of de-tecting nonprogressive and nonlethal invasive cancer are considered.
Limitation:
Results are not applicable to carriers of
BRCA1
or 
BRCA2
mutations.
Conclusion:
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.
PrimaryFundingSource:
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.
2011;155:10-20.
www.annals.org
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.
M
ETHODS
PerspectiveandThreshold
Our analysis was based on data from women in theUnited States and assumed the perspective of a national health
 See also:
Print
Editors’ Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Editorial comment. . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Web-Only
Conversion of graphics into slidesSupplement
Annals of Internal Medicine
Original Research
10
© 2011 American College of Physicians
 
payer. Two cost-effectiveness thresholds were considered:$100 000 or less and $50 000 or less per quality-adjusted life-year (QALY) gained.
ModelStructure
 We constructed a Markov cost–utility model to com-pare the lifetime costs and health benefits of having mam-mography annually, biennially, or every 3 to 4 years or nothaving mammography. Each strategy included 6 healthstates: healthy (no breast cancer); ductal carcinoma in situ(DCIS); localized, regional, or distant invasive breast can-cer; and death. All women started in the healthy state andcould stay healthy, die, or transition to DCIS or one of theinvasive breast cancer states. Those with DCIS could tran-sition to an invasive breast cancer state or die of causesother than breast cancer. Those with invasive breast cancercould die of breast cancer or other causes. No transitionsfrom localized to regional or distant or from regional todistant breast cancer were included; stage distribution atthe time of diagnosis would capture the effects of thesetransitions up to the point of diagnosis, and our datatracked mortality and costs over years since diagnosis ac-cording to stage at the time of diagnosis.
BreastCancerIncidenceRates
 We estimated the incidence rates of invasive breastcancer and DCIS by age (
Supplement
, available at www .annals.org) by using 1975 to 2005 data from the Surveil-lance, Epidemiology, and End Results (SEER) database(22). Data from Tice and colleagues’ study (20) were usedto adjust these rates for breast density (
Figure 1
), history of breast cancer in a first-degree relative, and history of breastbiopsy (
Supplement
).Ductal carcinoma in situ is usually discovered by screening mammography (23). The incidence of DCIS wasassumed to be 4-fold higher among women who had mam-mography than among those who did not (23, 24). We
Context 
The optimal timing and frequency of screening mammog-raphy are controversial.
Contribution
This analysis found that the cost-effectiveness of screeningmammography depended on a woman’s age, breast den-sity, family history, and history of breast biopsy. Mam-mography every 2 years was cost-effective for womenaged 40 to 49 years with relatively high breast density or additional risk factors for breast cancer. Mammographyevery 3 to 4 years was cost-effective for women aged50 to 79 years with low breast density and no other riskfactors.
Implication
Decisions about when and how often to have screeningmammography could be personalized on the basis of riskfactors.
 —The Editors
Figure 1.
Markovmodelofpossiblestatetransitions.
HealthyLocal invasivebreast cancer Death fromother causesDeath frombreast cancer Regionalinvasivebreast cancer DCISDistant invasivebreast cancer 
The dotted-and-dashed lines indicate transitions from the healthy state; the dashed lines indicate transitions from the DCIS state; and the solid linesindicate transitions from the invasive breast cancer states. DCIS
ductal carcinoma in situ.
Original Research
Personalizing Mammography by Breast Density and Other Risk Factors
www.annals.org
5 July 2011Annals of Internal MedicineVolume 155 • Number 1
11
 
also assumed that women with DCIS who had no mam-mography would have a 3.4-fold greater risk for subse-quent invasive breast cancer than healthy women, andthose with DCIS who had mammography would have a1.9-fold greater risk (25, 26).
StagesofIncidentInvasiveBreastCancer 
 We assumed that invasive breast cancer is more likely to be diagnosed at an advanced stage in women who haveno or less frequent screening mammography. The propor-tions of women in each stage of invasive breast cancer whohave screening mammography were estimated by usingdata (number of years between the date invasive breastcancer was detected and the most recent previous mammo-gram) from the Breast Cancer Surveillance Consortium(BCSC) from 1996 through 2006 (27). Women who lasthad mammography 0.5 to 1.5 years (6000 women), 1.5 to2.5 years (2846 women), or 2.5 to 5.5 years (1433 womenmean, 3.5 years) before the date on which their cancer was
Table 1.
Base-CaseValuesforEachBreastCancerStage
CharacteristicBreastCancerStageDuctalCarcinomaInSituLocalInvasiveRegionalInvasiveDistantInvasiveBreastcancercost,
$*
First year 8893 11 710 22 139 34 192After first year 777 554 3209 10 061Last year of life31 694 37 516 52 620
Proportionofhealthy-stateQALYslost
First year 0.096 0.154 0.247 0.247After first year 0.000 0.020 0.095 0.168
Proportionsineachstage‡
Aged 40–49 yNo mammography§ 0.515 0.431 0.079Mammography every 34 years§ 0.643 0.327 0.030Low breast density 0.676 0.296 0.028High breast density 0.617 0.353 0.031Mammography every 2 yearsLow breast density 0.713 0.269 0.018High breast density 0.657 0.323 0.020Aged 50–59 yNo mammography§ 0.483 0.443 0.074Mammography every 34 years§ 0.660 0.323 0.017
Low breast density0.703 0.276 0.021High breast density** 0.647 0.330 0.023Mammography every 2 yearsLow breast density0.737 0.249 0.014High breast density** 0.685 0.299 0.015Aged 60–69 yNo mammography§ 0.496 0.407 0.097Mammography every 34 years§ 0.695 0.273 0.032
Low breast density0.740 0.234 0.026High breast density** 0.689 0.283 0.028Mammography every 2 yearsLow breast density0.771 0.213 0.016High breast density** 0.724 0.258 0.018Aged 70–79 yNo mammography§ 0.533 0.378 0.080Mammography every 34 years§ 0.764 0.219 0.017Low breast density0.775 0.209 0.015High breast density** 0.731 0.252 0.017Mammography every 2 yearsLow breast density0.803 0.187 0.010High breast density** 0.762 0.227 0.011
BI-RADS
Breast Imaging Reporting and Data System; QALY 
quality-adjusted life-year.
*
In 2008 U.S. dollars.
Applied only to women who are dying of breast cancer and not other causes.
Stage distributions for annual mammography (not shown) did not significantly differ from those for biennial mammography. Distributions by age and screening frequency  were calculated from Breast Cancer Surveillance Consortium data (
Supplement
, available at www.annals.org).
§
Stage distributions stratified by age only.
Proportion does not fall between the estimates for high and low breast density because of a very slight estimation error when the stage distributions stratified by both ageand breast density were estimated from generalized ordinal logit regressions. Sensitivity analyses showed that this error did not significantly influence the costs per QALY gained (data not shown).
BI-RADS category 1 or 2 breast density.
**
BI-RADS category 3 or 4 breast density.
Original Research
Personalizing Mammography by Breast Density and Other Risk Factors
12
5 July 2011Annals of Internal MedicineVolume 155 • Number 1
www.annals.org

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