Assessment of the Benefits and Cost-Effectiveness of Population-Based Breast Cancer Screening in Urban China: A Model-Based Analysis

Document Type : Original Article

Authors

1 Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

2 Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

3 Robotics and Mechatronics (RaM) Group, Faculty of Electrical Engineering Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, The Netherlands

4 Department of Epidemiology and Health Statistics, School of Public Health, Tianjin Medical University, Tianjin, China

5 Collaborative Innovation Center of Chronic Disease Prevention and Control, School of Public Health, Tianjin Medical University, Tianjin, China

Abstract

Background 
To decrease the burden of breast cancer (BC), the Chinese government recently introduced biennial mammography screening for women aged 45-70 years. In this study, we assess the effectiveness and cost-effectiveness of implementing this programme in urban China using a micro-simulation model.

Methods 
The ‘Simulation Model on radiation Risk and breast cancer Screening’ (SiMRiSc) was applied, with parameters updated based on available data for the Chinese population. The base scenario was biennial mammography screening for women aged 45-70 years, and this was compared to a reference population with no screening. Seven alternative scenarios were then simulated by varying the screening intervals and participant ages. This analysis was conducted from a societal perspective. The discounted incremental cost- effectiveness ratio (ICER) was compared to a threshold of triple the gross domestic product (GDP) per life years gained (LYG), which was 30 785 USD/LYG. Univariate sensitivity analyses were conducted to evaluate model robustness. In addition, a budget impact analysis was performed by comparing biennial screening with no screening at a time horizon of 10 years.

Results 
Compared with no screening, the base scenario was cost-effective in urban China, giving a discounted average cost-effectiveness ratio (ACER) of 17 309 USD/LYG. The model was most sensitive to the cost of mammography per screen, followed by mean size of self- detected tumours, mammographic breast density and the cumulative lifetime risk of BC. The efficient frontier showed that at a threshold of 30 785 USD/LYG, the base scenario was the optimal scenario with a discounted ICER of 25 261 USD/LYG. Over 10 years, screening would incur a net cost of almost 38.1 million USD for a city with 1 million citizens.
 
Conclusion 
Compared to no screening, biennial mammography screening for women aged from 45-70 is cost-effective in urban China.

Keywords


  1. Zhang ML, Peng P, Wu CX, et al. [Report of breast cancer incidence and mortality in China registry regions, 2008-2012]. Zhonghua Zhong Liu Za Zhi. 2019;41(4):315-320. doi:10.3760/cma.j.issn.0253-3766.2019.04.013
  2. Zuo TT, Zheng RS, Zeng HM, Zhang SW, Chen WQ. Female breast cancer incidence and mortality in China, 2013. Thorac Cancer. 2017;8(3):214-218. doi:10.1111/1759-7714.12426
  3. Sung H, Rosenberg PS, Chen WQ, et al. Female breast cancer incidence among Asian and Western populations: more similar than expected. J Natl Cancer Inst. 2015;107(7):djv107. doi:10.1093/jnci/djv107
  4. Zhou M, Wang H, Zeng X, et al. Mortality, morbidity, and risk factors in China and its provinces, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2019;394(10204):1145-1158. doi:10.1016/s0140-6736(19)30427-1
  5. Chen C, Sun S, Yuan JP, et al. Characteristics of breast cancer in Central China, literature review and comparison with USA. Breast. 2016;30:208-213. doi:10.1016/j.breast.2016.01.004
  6. de Munck L, Fracheboud J, de Bock GH, den Heeten GJ, Siesling S, Broeders MJM. Is the incidence of advanced-stage breast cancer affected by whether women attend a steady-state screening program? Int J Cancer. 2018;143(4):842-850. doi:10.1002/ijc.31388
  7. Myers ER, Moorman P, Gierisch JM, et al. Benefits and harms of breast cancer screening: a systematic review. JAMA. 2015;314(15):1615-1634. doi:10.1001/jama.2015.13183
  8. Huang Y, Dai H, Song F, et al. Preliminary effectiveness of breast cancer screening among 1.22 million Chinese females and different cancer patterns between urban and rural women. Sci Rep. 2016;6:39459. doi:10.1038/srep39459
  9. Dong H, Huang Y, Song F, et al. Improved performance of adjunctive ultrasonography after mammography screening for breast cancer among Chinese females. Clin Breast Cancer. 2018;18(3):e353-e361. doi:10.1016/j.clbc.2017.07.014
  10. Huang NS, Liu MY, Chen JJ, et al. Surgical management of breast cancer in China: a 15-year single-center retrospective study of 18,502 patients. Medicine (Baltimore). 2016;95(45):e4201. doi:10.1097/md.0000000000004201
  11. Breast cancer screening guideline for Chinese women. Cancer Biol Med. 2019;16(4):822-824. doi:10.20892/j.issn.2095-3941.2019.0321
  12. Wang F, Yu ZG. Current status of breast cancer prevention in China. Chronic Dis Transl Med. 2015;1(1):2-8. doi:10.1016/j.cdtm.2015.02.003
  13. Husereau D, Drummond M, Petrou S, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. Value Health. 2013;16(2):e1-5. doi:10.1016/j.jval.2013.02.010
  14. Koleva-Kolarova RG, Daszczuk AM, de Jonge C, et al. A modelling study to evaluate the costs and effects of lowering the starting age of population breast cancer screening. Maturitas. 2018;109:81-88. doi:10.1016/j.maturitas.2017.12.009
  15. de Bock GH, Vermeulen KM, Jansen L, et al. Which screening strategy should be offered to women with BRCA1 or BRCA2 mutations? a simulation of comparative cost-effectiveness. Br J Cancer. 2013;108(8):1579-1586. doi:10.1038/bjc.2013.149
  16. Lu W, Greuter MJ, Schaapveld M, Vermeulen KM, Wiggers T, de Bock GH. Safety and cost-effectiveness of shortening hospital follow-up after breast cancer treatment. Br J Surg. 2012;99(9):1227-1233. doi:10.1002/bjs.8850
  17. Greuter MJ, Jansen-van der Weide MC, Jacobi CE, et al. The validation of a simulation model incorporating radiation risk for mammography breast cancer screening in women with a hereditary-increased breast cancer risk. Eur J Cancer. 2010;46(3):495-504. doi:10.1016/j.ejca.2009.10.030
  18. Jacobi CE, Nagelkerke NJ, van Houwelingen JH, de Bock GH. Breast cancer screening, outside the population-screening program, of women from breast cancer families without proven BRCA1/BRCA2 mutations: a simulation study. Cancer Epidemiol Biomarkers Prev. 2006;15(3):429-436. doi:10.1158/1055-9965.epi-05-0223
  19. Isheden G, Humphreys K. Modelling breast cancer tumour growth for a stable disease population. Stat Methods Med Res. 2019;28(3):681-702. doi:10.1177/0962280217734583
  20. Phi XA, Greuter MJW, Obdeijn IM, et al. Should women with a BRCA1/2 mutation aged 60 and older be offered intensified breast cancer screening? - a cost-effectiveness analysis. Breast. 2019;45:82-88. doi:10.1016/j.breast.2019.03.004
  21. He J, Chen WQ. Chinese Cancer Registry Annual Report 2019. Beijing: Press of Military Medical Sciences; 2019:204-205.
  22. National Bureau of Statistics (NBS). China Population and Employment Statistics Yearbook 2016. NBS; 2016.
  23. Kuroishi T, Tominaga S, Morimoto T, et al. Tumor growth rate and prognosis of breast cancer mainly detected by mass screening. Jpn J Cancer Res. 1990;81(5):454-462. doi:10.1111/j.1349-7006.1990.tb02591.x
  24. Kim BK, Choi YH, Nguyen TL, et al. Mammographic density and risk of breast cancer in Korean women. Eur J Cancer Prev. 2015;24(5):422-429. doi:10.1097/cej.0000000000000099
  25. Leung AW, Mak J, Cheung PS, Epstein RJ. Clinicopathological correlates in a cohort of Hong Kong breast cancer patients presenting with screen-detected or symptomatic disease. Hong Kong Med J. 2007;13(3):194-198.
  26. Chou CP, Pan HB, Hsu GC, et al. Assessing the first 3 years of Taiwan's nationwide population-based mammography screening program. Breast J. 2012;18(5):498-499. doi:10.1111/j.1524-4741.2012.01289.x
  27. Kang M, Zhao Y, Huang Y, Li J, Liu L, Li H. [Accuracy and direct medical cost of different screening modalities for breast cancer among Chinese women]. Zhonghua Zhong Liu Za Zhi. 2014;36(3):236-240.
  28. Honjo S, Ando J, Tsukioka T, et al. Relative and combined performance of mammography and ultrasonography for breast cancer screening in the general population: a pilot study in Tochigi Prefecture, Japan. Jpn J Clin Oncol. 2007;37(9):715-720. doi:10.1093/jjco/hym090
  29. Ohta K, Kasahara Y, Tanaka F, Maeda H. Is clinical breast examination effective in Japan? Consideration from the age-specific performance of breast cancer screening combining mammography with clinical breast examination. Breast Cancer. 2016;23(2):183-189. doi:10.1007/s12282-014-0544-0
  30. Chen CY, Tzeng WS, Tsai CC, Mak CW, Chen CH, Chou MC. Adjusting mammography--audit recommendations in a lower-incidence Taiwanese population. J Am Coll Radiol. 2008;5(9):978-985. doi:10.1016/j.jacr.2008.05.009
  31. Kang M, Pang Y, Li JY, Liu LH, Liu XT. [Accuracy evaluation of mammography in the breast cancer screening in Asian women: a community-based follow-up study and meta analysis]. Zhonghua Zhong Liu Za Zhi. 2010;32(3):212-216.
  32. Moon HJ, Jung I, Park SJ, Kim MJ, Youk JH, Kim EK. Comparison of cancer yields and diagnostic performance of screening mammography vs. supplemental screening ultrasound in 4394 women with average risk for breast cancer. Ultraschall Med. 2015;36(3):255-263. doi:10.1055/s-0034-1366288
  33. Lee EH, Kim KW, Kim YJ, et al. Performance of screening mammography: a report of the alliance for breast cancer screening in Korea. Korean J Radiol. 2016;17(4):489-496. doi:10.3348/kjr.2016.17.4.489
  34. Suzuki A, Kuriyama S, Kawai M, et al. Age-specific interval breast cancers in Japan: estimation of the proper sensitivity of screening using a population-based cancer registry. Cancer Sci. 2008;99(11):2264-2267. doi:10.1111/j.1349-7006.2008.00926.x
  35. Medical service prices. Tianjin: Tianjin Development and Reform Commission Internet; http://fzgg.tj.gov.cn/gzcx/syjgcx/ylfw/201307/t20130708_30051.shtml. Accessed October 10, 2019.
  36. Liao XZ, Shi JF, Liu JS, et al. Medical and non-medical expenditure for breast cancer diagnosis and treatment in China: a multicenter cross-sectional study. Asia Pac J Clin Oncol. 2018;14(3):167-178. doi:10.1111/ajco.12703
  37. CCEMG - EPPI-Centre Cost Converter Internet. https://eppi.ioe.ac.uk/costconversion/default.aspx. Updated April 29, 2019. Accessed October 10, 2019.
  38. Overview of 2012 Community Health and Health Promotion Business Report. Japan: Ministry of Health, Labour and Welfare Internet. https://www.mhlw.go.jp/toukei/saikin/hw/c-hoken/12/index.html. Assessed June 20,2020.
  39. Iwamoto T, Kumamaru H, Miyata H, et al. Distinct breast cancer characteristics between screen- and self-detected breast cancers recorded in the Japanese Breast Cancer Registry. Breast Cancer Res Treat. 2016;156(3):485-494. doi:10.1007/s10549-016-3770-7
  40. Cancer Information Service, National Cancer Center, Japan. https://ganjoho.jp/en/professional/statistics/table_download.html. Assessed June 20, 2020.
  41. Hamashima C, Hamashima CC, Hattori M, et al. The Japanese guidelines for breast cancer screening. Jpn J Clin Oncol. 2016;46(5):482-492. doi:10.1093/jjco/hyw008
  42. China guidelines for pharmacoeconomic evaluations. Beijing: China Center for Health Economics Research; 2019.
  43. GDP per capita (current US$) internet. Washington, DC: The World Bank; Available from: http://data.worldbank.org/indicator/NY.GDP.PCAP.CD. Accessed January 10, 2021.
  44. Tan-Torres Edejer T, Baltussen R, Adam T, et al. WHO Guide to Cost-Effectiveness Analysis. Geneva: World Health Organization; 2003.
  45. UN Population Division. World Population Prospects. Available from: https://esa.un.org/unpd/wpp/. Accessed January 20, 2021.
  46. National Bureau of Statistics of China Internet. Available from: http://data.stats.gov.cn/easyquery.htm?cn=C01&zb=A0301&sj=2018. Accessed October 10, 2019.
  47. Sun YS, Zhao Z, Yang ZN, et al. Risk factors and preventions of breast cancer. Int J Biol Sci. 2017;13(11):1387-1397. doi:10.7150/ijbs.21635
  48. Wong IO, Kuntz KM, Cowling BJ, Lam CL, Leung GM. Cost effectiveness of mammography screening for Chinese women. Cancer. 2007;110(4):885-895. doi:10.1002/cncr.22848
  49. Woo PP, Kim JJ, Leung GM. What is the most cost-effective population-based cancer screening program for Chinese women? J Clin Oncol. 2007;25(6):617-624. doi:10.1200/jco.2006.06.0210
  50. Sun L, Legood R, Sadique Z, Dos-Santos-Silva I, Yang L. Cost-effectiveness of risk-based breast cancer screening programme, China. Bull World Health Organ. 2018;96(8):568-577. doi:10.2471/blt.18.207944
  51. Leong SP, Shen ZZ, Liu TJ, et al. Is breast cancer the same disease in Asian and Western countries? World J Surg. 2010;34(10):2308-2324. doi:10.1007/s00268-010-0683-1
  52. Loy EY, Molinar D, Chow KY, Fock C. National breast cancer screening programme, Singapore: evaluation of participation and performance indicators. J Med Screen. 2015;22(4):194-200. doi:10.1177/0969141315589644
  53. Houssami N, Hunter K. The epidemiology, radiology and biological characteristics of interval breast cancers in population mammography screening. NPJ Breast Cancer. 2017;3:12. doi:10.1038/s41523-017-0014-x
  54. Song QK, Li J, Huang R, et al. Age of diagnosis of breast cancer in china: almost 10 years earlier than in the United States and the European union. Asian Pac J Cancer Prev. 2014;15(22):10021-10025. doi:10.7314/apjcp.2014.15.22.10021
  55. Duffy SW, Vulkan D, Cuckle H, et al. Effect of mammographic screening from age 40 years on breast cancer mortality (UK Age trial): final results of a randomised, controlled trial. Lancet Oncol. 2020;21(9):1165-1172. doi:10.1016/s1470-2045(20)30398-3
  56. Chen TH, Yen AM, Fann JC, et al. Clarifying the debate on population-based screening for breast cancer with mammography: a systematic review of randomized controlled trials on mammography with Bayesian meta-analysis and causal model. Medicine (Baltimore). 2017;96(3):e5684. doi:10.1097/md.0000000000005684
  57. Robberstad B. QALYs vs DALYs vs LYs gained: What are the differences, and what difference do they make for health care priority setting? Nor Epidemiol. 2005;15(2):183-191. doi:10.5324/nje.v15i2.217
  58. Tengs TO. Cost-effectiveness versus cost-utility analysis of interventions for cancer: does adjusting for health-related quality of life really matter? Value Health. 2004;7(1):70-78. doi:10.1111/j.1524-4733.2004.71246.x
  59. Davidović M, Zielonke N, Lansdorp-Vogelaar I, Segnan N, de Koning HJ, Heijnsdijk EA. Disability-Adjusted Life Years Averted Versus Quality-Adjusted Life Years Gained: A Model Analysis for Breast Cancer Screening. Value Health. 2021;24(3):353-360. doi:10.1016/j.jval.2020.10.018
  60. Korean Statistical Information Service. Available from: https://kosis.kr/eng. Accessed January 11, 2021.
  61. Singapore Ministry of Health. Available from: www.moh.gov.sg. Accessed January 11, 2021.
  62. van Seijen M, Lips EH, Thompson AM, et al. Ductal carcinoma in situ: to treat or not to treat, that is the question. Br J Cancer. 2019;121(4):285-292. doi:10.1038/s41416-019-0478-6
  63. Morris E, Feig SA, Drexler M, Lehman C. Implications of overdiagnosis: impact on screening mammography practices. Popul Health Manag. 2015;18(Suppl 1):S3-11. doi:10.1089/pop.2015.29023.mor
  64. Yip W, Fu H, Chen AT, et al. 10 years of health-care reform in China: progress and gaps in universal health coverage. Lancet. 2019;394(10204):1192-1204. doi:10.1016/s0140-6736(19)32136-1
  65. Fan L, Strasser-Weippl K, Li JJ, et al. Breast cancer in China. Lancet Oncol. 2014;15(7):e279-289. doi:10.1016/s1470-2045(13)70567-9
  66. Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, et al. Challenges to effective cancer control in China, India, and Russia. Lancet Oncol. 2014;15(5):489-538. doi:10.1016/s1470-2045(14)70029-4