Expected 10-year treatment cost of breast cancer detected within and outside a public screening program in Norway

Costs and Effects of Implementing Digital Tomosynthesis in a Population-Based Breast Cancer Screening Program: Predictions Using Results from the To-Be Trial in Norway

BACKGROUND

Although several studies from Europe and the US have shown promising screening results favoring digital breast tomosynthesis compared with standard digital mammography (DM), both costs and effects of implementing tomosynthesis in routine screening programs remain uncertain. The cost effectiveness of using tomosynthesis in routine screening is debated in the literature, and model inputs from randomized trials are lacking. Using parameters mainly from a randomized controlled trial (the To-Be trial), we simulated costs and effects of implementing tomosynthesis in the national screening program BreastScreen Norway.

METHODS

The To-Be trial was performed in Bergen from 2016 to 2017 within BreastScreen Norway, where females were randomized to either digital breast tomosynthesis including synthetic mammograms (DBT) or DM. The trial was followed by a cohort study offering all females DBT in 2018-2019. The trial included over 37,000 females, and allowed for estimation of short-term costs and effects related to screening, recall examinations and cancer detection. Using these and recent Norwegian estimates for 10-year stage-specific survival and treatment costs, the cost effectiveness of replacing DM with DBT in BreastScreen Norway was simulated in a decision tree model with probabilistic sensitivity analyses. Outcomes included false-positive screening results, screen-detected and interval cancers, stage at diagnosis, all-cause deaths, life-years gained, costs at recall and treatment and incremental cost-effectiveness ratio.

RESULTS

The estimated additional cost of DBT was €8.10. Simulating ten rounds of screening from 2018 and 10-year survival and costs, 500 deaths were averted and 2300 life-years gained at an additional screening cost of €29 million for females screened with DBT versus DM. Taking over-diagnosis, recall and treatment costs into account, DBT was dominant in the deterministic analysis. The incremental cost-effectiveness ratio indicated cost savings of €1400 per life-year gained. Probabilistic sensitivity analyses showed that DBT was cost effective in over 50% of the simulations at all willingness-to-pay levels per life-year gained, and in 80% of the simulations at levels above €22,000. If willingness-to-pay levels up to €35,000 were assumed, DBT would be cost effective in over 50% of the simulations for additional costs of DBT of up to €32, almost four times the estimated additional cost of €8.10.

CONCLUSION

DBT may be cost effective if implemented in BreastScreen Norway. However, generalizability of results could depend on factors varying between countries, such as recall rates, program sensitivity and specificity, treatment cost and willingness-to-pay levels.

Experience using a portable X-ray system at the scene transported by a physician-staffed helicopter

Background

Fujifilm (Tokyo, Japan) developed a portable X‐ray system called the CALNEO Xair, which can be carried by a physician. The X‐ray radiation machine weighs 3.5 kg. The dimensions are: height, 144 mm; length, 148 mm; width, 258 mm.

Case Presentation

When a 33‐year‐old woman driving a car made a right turn at a crossroad, her car hit another car, causing her vehicle to tip onto its side. Staff of the doctor helicopter checked her at the scene, and the findings of chest and pelvic X‐ray were all negative. She received a diagnosis of cervical sprain and pelvic contusion and was transferred to a local hospital by ambulance.

Conclusion

This is the first report of a case evaluated by a portable X‐ray system at the scene, under transportation by a doctor helicopter. This system could be useful for undertaking prehospital assessment and medical treatment.

Cancer costs and outcomes for common cancer sites in the Finnish population between 2009-2014

BACKGROUND

The cost of cancer and outcomes of cancer care have been discussed a lot since cancer represents 3-6% of total healthcare costs and cost estimations have indicated growing costs. There are studies considering the cost of all cancers, but studies focusing on the cost of disease and outcomes in most common cancer sites are limited. The objective of this study was to analyze the development of the costs and outcomes in Finland between 2009 and 2014 per cancer site.

METHODS

The National cost, episode and outcomes data were obtained from the National register databases based on International Statistical Classification of Diseases (ICD)-10 diagnosis codes. Cost data included both the direct and indirect costs. Two hospitals were used to validate the costs of care. The outcome measures included relative survival rate, mortality, sick leave days per patient and number of new disability pensions.

FINDINGS

The outcomes of cancer care in most common cancer sites have improved in Finland between 2009-2014. The real costs per new cancer patient decreased in seven out of ten most common cancer sites. The significance of different cost components differ significantly between the different cancer sites. The share of medication costs of the total cost of all cancers increased, but decreased for the five most common cancer sites.

INTERPRETATION

The changes in the cost components indicate that the length of stay has shortened in special care and treatment methods have developed towards outpatient care. This partially explains the decrease of costs. Also, at the same time outcomes improved, which indicates that decrease in costs did not come at the expense of treatment quality. As the survival rates increase, the relevance of mortality measures decreases and the relevance of other, patient-relevant outcome measures increases. In the future, the outcomes and costs of health care systems should be assessed routinely for the most common patient groups.

Return on Investment Analysis of Breast Cancer Screening and Downstaging in Egypt: Implications for Developing Countries

OBJECTIVE

The aim of this study was to perform a return-on-investment (ROI) analysis of a breast cancer screening program in Egypt by comparing net profit in treatment costs saved to program cost investment.

METHODS

The breast cancer downstaging program targeted women living in an Egyptian slum, where residents have low access to health care. Program costs were estimated by using data from interviews with program administrative staff. Screening and treatment costs were estimated by using Ministry of Health medical reimbursement data. Estimates for expected rates of downstaging were modeled on the basis of data from a previous study. ROI, or relative cost savings, was calculated by comparing treatment cost savings to costs for the screening program. A baseline ROI for facility-based screening was calculated, followed by ROIs for different scenarios.

RESULTS

Average per-person treatment cost for screened and unscreened patients was estimated to be $28,632 and $58,170, respectively, with a cumulative lifetime risk of 6.36%. Total screening program cost per person was $112.10. The study estimated an expected decrease in late-stage breast cancer diagnosis by 13.7% as a result of the screening program, saving $4,049 in treatment costs per individual diagnosed. The analysis resulted in a positive ROI of 133% for facility-based screening.

CONCLUSIONS

Breast cancer represents an increasing burden on health care in Egypt and other developing countries. This study concludes that a community-based downstaging program resulted in a positive ROI, or overall cost-savings. The findings inform that policymakers in low-income and middle-income countries may consider implementing community-based downstaging programs for breast cancer.

Cost-effectiveness of the Norwegian breast cancer screening program

The Norwegian Breast Cancer Screening Programme (NBCSP) has a nation-wide coverage since 2005. All women aged 50-69 years are invited biennially for mammography screening. We evaluated breast cancer mortality reduction and performed a cost-effectiveness analysis, using our microsimulation model, calibrated to most recent data. The microsimulation model allows for the comparison of mortality and costs between a (hypothetical) situation without screening and a situation with screening. Breast cancer incidence in Norway had a steep increase in the early 1990s. We calibrated the model to simulate this increase and included recent costs for screening, diagnosis and treatment of breast cancer and travel and productivity loss. We estimate a 16% breast cancer mortality reduction for a cohort of women, invited to screening, followed over their complete lifetime. Cost-effectiveness is estimated at NOK 112,162 per QALY gained, when taking only direct medical costs into account (the cost of the buses, examinations, and invitations). We used a 3.5% annual discount rate. Cost-effectiveness estimates are substantially below the threshold of NOK 1,926,366 as recommended by the WHO guidelines. For the Norwegian population, which has been gradually exposed to screening, breast cancer mortality reduction for women exposed to screening is increasing and is estimated to rise to ∼30% in 2020 for women aged 55-80 years. The NBCSP is a highly cost-effective measure to reduce breast cancer specific mortality. We estimate a breast cancer specific mortality reduction of 16-30%, at the cost of 112,162 NOK per QALY gained.