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Cost-Effectiveness Analysis of a Screening Program for Breast Cancer
in Vietnam
Lan Hoang Nguyen
1,2
, Wongsa Laohasiriwong
3,
, John Frederick Stewart
4
, Pamela Wright
5
, Yen Thi Bach Nguyen
6
,
Peter C. Coyte
7
1
PhD Program in Public Health, Graduate School, Khon Kaen University, Khon Kaen, Thailand;
2
Hue College of Medicine and Pharmacy, Hue University, Hue City,
Vietnam;
3
Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand;
4
Department of Economics, University of North Carolina, Chapel Hill, USA;
5
Medical Committee Netherlands-Vietnam, Amsterdam, Netherlands;
6
Institute for Preventative Medicine and Public Health, Hanoi Medical University, Hanoi,
Vietnam;
7
Institute of Health Policy, Management & Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
A B S T R A C T
Objective: This study aimed to evaluate the cost-effectiveness of a
screening program for breast cancer from the health care payers
perspective. Methods: A Markov model was used to compare costs
and effects of an annual screening program using clinical breast
examination (CBE) with the absence of screening on a cohort of
4,103,285 asymptomatic women aged 40 years. The model was
analyzed over the cohorts lifetime under the assumption that women
participated in the screening program annually for 15 years. The
model integrated both epidemiological and cost data for breast cancer
from prior Vietnamese studies. Costs were measured in 2008 US
dollars. Costs and effects were discounted annually at 3%. The
incremental cost-effectiveness ratio (ICER) was dened as the differ-
ence in cost per life-years saved (LYS). One-way and probabilistic
sensitivity analyses were implemented to assess the uncertainty of
inputs. Results: The ICER for the breast cancer screening program
with CBE was US $994.96 per LYS compared with the absence of
screening. Earlier initiation of the program at age 35 years increased
the ICER to US $1196.68 per LYS, while extending the duration of time
screened to age 60 years decreased the ICER. Changing the partic-
ipation rate to 70%, reducing the specicity of CBE testing, and
increasing the cost of the screening program by 30% raised ICER
estimates to US $1419.32, US $1124.15, and US $1292.03 per LYS,
respectively. Conclusion: Breast cancer screening with CBE for
women aged 40 to 55 years is considered very cost-effective in
Vietnam according to the World Health Organization criteria.
Keywords: breast cancer, clinical breast examination, cost-
effectiveness, screening program, Vietnam.
Copyright & 2013, International Society for Pharmacoeconomics and
Outcomes Research (ISPOR). Published by Elsevier Inc.
Introduction
Breast cancer is the most common cancer among women,
accounting for 23% of all female cancers. There were more than
1.3 million new cases and 458,503 deaths from breast cancer
worldwide in 2008 [1,2]. In developing countries, this disease has
been increasing by 5% each year while global incidence rates
have been increased by only 0.5% annually since 1990 [1,3].
Survival from the disease has increased in developed countries
because of improvements in screening practices and in treatment
over recent decades, but survival in developing countries remains
low [1]. Many investigations have shown that poor cancer
survival is largely due to late stage presentation and due to
limitation in both diagnostic techniques and treatment capacities
in less developed countries [4,5]. The World Health Organization
(WHO) recommends early detection as an effective solution to
improve health outcomes because the detection of early stage
breast cancer lowers both mortality and treatment costs [3].
Many techniques for breast cancer screening have been
applied in the developed world in the last few decades, including
breast self-examination (BSE), clinical breast examination (CBE),
and mammography. The cost and effectiveness of each strategy
varies according to the sociocultural context, clinical practices,
and target population. The cost-effectiveness of screening mam-
mography was estimated as US $902 to US $1,946 per life-year
saved (LYS) in India, US $2,450 to US $14,790 per LYS in Europe,
and US $28,600 to US $47,900 per LYS in the United States. Biennial
CBE was evaluated in India and yielded a cost-effectiveness ratio
of US $522 per LYS. Moreover, CBE performed annually from ages
40 to 60 years was nearly as efcacious as biennial mammography
screening while incurring only half the net costs [6,7]. Therefore,
CBE may be a suitable option for countries in economic transition
where incidence rates are on the rise but where resources are
limited and technical complexities do not permit widespread
screening by mammography [610].
An important question for developing countries is whether CBE
can be applied as a model for breast cancer screening to lower
mortality and morbidity. Vietnam is a lower middle-income coun-
try with gross domestic product (GDP) per capita in 2008 of about
$1070 [11]. Breast cancer is the most common cancer among
women, and its incidence has increased steadily over time. The
age-standardized rate has increased from 17.4 per 100,000 in the
2212-1099/$36.00 see front matter Copyright & 2013, International Society for Pharmacoeconomics and Outcomes Research (ISPOR).
Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.vhri.2013.02.004
Conict of Interest: The authors have indicated that they have no conicts of interest with regard to the content of this article.
E-mail: drwongsa@gmail.com.

Address correspondence to: Wongsa Laohasiriwong, Faculty of Public Health, Khon Kaen University, Thailand.
VA L U E I N H E A LT H R E G I O N A L I S S U E S 2 ( 2 0 1 3 ) 2 1 2 8
year 2000 to 29.9 per 100,000 in 2010, thereby accounting for 12,533
newly diagnosed cases in that year [12]. Most breast cancer
patients present at hospitals in an advanced stage when the
disease cannot be effectively treated or cured [13]. As a conse-
quence, survival probability for breast cancer has been poor [14,15].
Screening Policy for Breast Cancer in Vietnam
In line with WHO guidelines, a National Cancer Control Program
(NCCP) was introduced in 2008 in selected regions of Vietnam. The
general objectives of the NCCP were to reduce morbidity and
mortality due to cancer and to improve the quality of life of
patients with cancer. One specic objective of this program was to
reduce breast cancer mortality. To achieve this goal, six regions in
which cancer registries were established and operating initiated
an organized screening program designed to detect both breast
and cervical cancer in 2008 [16]. CBE screening was used to detect
breast cancer. Although the screening policy focused on women
aged 40 to 55 years, there were differences in target age among
the regions (i.e., women aged 3560 years in Hanoi, 4055 years in
Hai Phong, 3050 years in Thua Thien Hue, and 4054 years in
Thai Nguyen). Moreover, only approximately 15% to 20% of the
total target population participated in the program in each region
in 2008 because of the scal constraints of the NCCP [1720]. The
budget was used for 1) program planning in each region; 2) staff
training to improve skills in detecting breast tumors through CBE
or BSE and in counseling for suspected cases; 3) implementing
communication to encourage women to participate in the screen-
ing program; and 4) implementing breast examination for tar-
geted women to detect breast tumors and to teach participants
how to undertake BSE. For suspected cases, conrmatory diag-
nosis occurred at specialized hospitals. The budget of the program
did not cover the costs for conrmatory diagnosis or for the
treatment of breast cancer when it is detected.
The aim of this study was to estimate the cost-effectiveness of
the screening program for breast cancer in Vietnam from the
perspective of health care payers. The results will assist policy-
makers in making the most effective use of the scarce resources
at their disposal.
Methods
A model in which both epidemiological and cost aspects for
breast cancer are included was designed to estimate the cost-
effectiveness of a screening program for breast cancer. In addi-
tion, sensitivity analyses were conducted to assess uncertainty
about the modeling parameters.
Markov Model Structure
We used a Markov model to simulate the impact of a CBE
screening program on breast cancer epidemiology over the
lifetime of a hypothetical cohort of women in Vietnam [21].
This model compared the cost and effects of an annual screen-
ing program using CBE to the same situation without such a
program. The cohort of 4,103,285 asymptomatic women aged 40
years was based on the 2008 population of Vietnam [22]. We
assumed that each woman would participate in the program
annually for 15 years unless breast cancer was detected or the
woman died of causes other than breast cancer. If cancer was
detected, women were followed-up for 5 years. We also
hypothesized that if patients were still alive after 5 years of
treatment, then they would have a normal life expectancy,
which for women in Vietnam is 74 years [22]. Each Markov
cycle lasted 1 year. The model represents the natural course of
breast cancer; it describes the transition of women between
four states (healthy, presence of breast cancer, death from
breast cancer, and death from other causes). The transition
between states was based on incidence rates for breast cancer,
breast cancer fatality, and mortality for other causes, as shown
in Fig. 1.
The model analyzed costs from a health care payers
perspective including patients, health services, and third par-
ties. Only direct costs were included in the analysis, which
comprised the payments for the screening tests, for additional
tests for suspected cases, and for treatment and follow-up care.
Although the exclusion of government subsidies for breast
cancer treatment results in an underestimate of the full health
system cost of the screening program, the perspective selected
offers useful information to policymakers on the nancial
burden of screening to health care payers. The same cohort
of women was analyzed in the absence of the screening
program under assumptions that were the same as those in
its presence. Incremental cost-effectiveness ratios (ICERs) were
dened as the cost per one LYS. Both costs and effects were
discounted at an annual rate of 3% according to the WHO
recommendations [23], and a lifetime time horizon was
adopted.
Fig. 1 Model of natural course of breast cancer. I1-4 represents stage-specic incidence rate of breast cancer by absence of
screening program and P1-4 represents stage-specic incidence rate of breast cancer by presence of screening program.
Death from other causes is difference between overall mortality (M) and breast cancer-specic mortality (m1-4).
VA L U E I N H E A LT H R E G I O N A L I S S U E S 2 ( 2 0 1 3 ) 2 1 2 8 22
Parameters and Data Resources
Breast cancer incidence
Stage- and age-specic breast cancer incidence was calculated by
age-specic incidence rates multiplied by the stage distribution
of breast cancer. Epidemiological statistics of breast cancer
between 2001 and 2007 in Vietnam were used in the absence of
screening data [24]. We assumed that these rates were uniform
over time. For the screening scenario, incidences were drawn
from a national screening program report between 2008 and 2010
[25]. In that report, however, the data on the stage distribution of
detected cases were incomplete. In 11 of 42 cases, the breast
cancer stage was not reported, and in all cases, stages III and IV
were combined. We, therefore, assumed that these 11 cases as
well as cases with advanced stages were allocated in the same
way as in the epidemiological statistics for breast cancer in
Vietnam before 2008 (Table 1).
Breast cancer mortality probability
Stage-specic mortality probabilities were drawn from a study of
breast cancer survival times for Vietnam and applied to both
scenarios. Because age was not an independent risk factor for
breast cancer mortality [26], the effect of age on breast cancer was
ignored in our model. We used breast cancer stage-specic mortal-
ity probabilities by year, with the assumption that the patients
would be free of disease at 5 years after diagnosis (Table 2). The
assumption is based on a recent study that found that women
with breast cancer have a good chance of remaining cancer-free if
they survive 5 years after being diagnosed [27]. The probability of
death from other causes was dened as the difference between
age-specic mortality probabilities from all causes and that from
breast cancer. The all-cause mortality probability by age group was
obtained from Vietnamese life tables for women in 2008 [22].
Cost Estimates
Screening program costs were derived from the budget of the
combined cervical and breast cancer screening programs, based
on the Circular with Guidelines for using budget of NCCP [25,28].
Besides specifying the costs for cervical cancer and costs for
clinical examination for breast cancer, we allocated other types
of cost equally between the two screening programs for cervical
and breast cancer with regard to equivalent inuence of activities
on the programs. The cost of additional tests was estimated by
multiplying the number of suspected cases and the unit cost of
additional tests. The number of suspected cases was dependent
on the specicity of the CBE. Because the validity of CBE has not
yet been evaluated in the screening program in Vietnam, we used
specicity estimates from a Japanese study (0.918 and 0.961 for
women aged 4049 years and 5069 years, respectively) [29].
Although this result was lower than that reported from other
studies conducted in Western countries [30], we chose this one
because of the similarity in Asian race including breast density of
the studied population. On the basis of common practice in
Vietnam at the time of the study, we also assumed that both
breast ultrasound and tumor biopsy were used to conrm the
diagnosis for breast cancer (Dr. Nguyen Dinh Tung, Oncology
Department, Hue Central Hospital, November 20, 2010, personal
communication). The unit cost of these tests was obtained from
the Hue Central Hospital [31]. Cost of the screening program and
the cost of additional tests are described in Table 3.
The cost of treatment and follow-up care for breast cancer
were estimated as the annual average treatment cost, from a
previous study in Central Vietnam that showed statistically
insignicant differences in total treatment cost among stages of
breast cancer [32]. In the absence of screening, only the costs of
treatment and follow-up care were included. All costs were
converted to 2008 by using Consumer Price Index in Vietnam
and reported in US dollars (US $1 16,817 VND) [33,34] (Table 4).
Outcome Estimates
The health effects of the screening program were expressed as
LYS. The difference in the number of life-years lost with and
without the screening program measures the incremental effec-
tiveness of the screening program. The number of life years lost
was calculated as follows:
Number of lives lost by age group Size of the population for
each age group mortality probability for that age group;
Life-years lost at age group Incremental life expectancy for
each age group number of lives lost by age group.
Total life-years lost for the total population was estimated by
the summation of the life-years lost across all age groups.
Incremental life expectancy was based on life tables for Viet-
namese women in 2008 [22].
Cost-effectiveness analysis
An ICER was calculated by dividing the difference in total costs by
the difference in life-years lost between the two scenarios.
Sensitivity analyses
Two types of sensitivity analyses were conducted: one-way
sensitivity analysis and probabilistic sensitivity analysis. First,
we conducted probabilistic sensitivity analysis to evaluate ef-
fects of parameter uncertainty on cost-effectiveness outcomes.
Uncertainty parameters were assigned suitable probability
Table 1 Breast cancer epidemiological data of two
scenarios.
Data No-
screening
scenario
Screening
scenario
Age-specic incidence

(per
100,000 women) (y)
3539 26.6 29.2
4044 41.1 71.8
4549 86.8 68.9
5054 94.6 82.1
55 128.0 23.3
Stage distribution
Stage I 10.9 24.3
Stage II 24.9 37.5
Stage III 47.5 29.1
Stage IV 16.7 9.1

For no-screening scenario, age-specic incidence is average of

those between 2001 and 2007. For screening scenario, age-specic
incidence is average of positive cases (with additional tests)
among all participants in the screening program between 2008
and 2010 (42 positive cases/70,980 participants).
Table 2 Mortality probability of breast cancer by
stage by year.
Year Stage I Stage II Stage III Stage IV
Year 1 0 0.0103 0.1033 0.4661
Year 2 0 0.0311 0.2289 0.6875
Year 3 0 0.0660 0.3225 0.7786
Year 4 0.0283 0.0940 0.3953 0.8177
Year 5 0.0400 0.1442 0.4689 0.8828
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distributions as recommended by Briggs et al. [21] (Table 5).
Monte Carlo simulation using Macros programed in Microsoft
Excel was recorded 2000 times to assess the impact of uncer-
tainty about the modeling parameters on the ICER estimates. The
number of times the simulation was performed is within the
range of iterations recommended by Barendregt [35]. The results
are presented in cost-effectiveness plane (C-E plane) and cost-
effectiveness acceptability curve (CEAC). The second was a one-
way sensitivity analysis to address the impact of the following
factors: a change in the participation rate, the specicity of CBE
testing, age at the initiation and cessation of the screening
program, the cost of the screening program, and the cost of
additional tests performed on the estimated ICER.
Results
Baseline Results
Base-case results are reported in Table 6. Implementation of the
annual screening program for breast cancer for women starting
at age 40 years and continuing for 15 years enhanced life-years by
0.033 years per person, that is, reduced the number of life-years
lost from 11.175 to 11.142 years. The average cost of diagnosis
and treatment for breast cancer was US $9.69 per person in the
no-screening scenario and US $42.99 per person under the
screening program. These results yielded an ICER of US $994.96
per life-year gained.
Probabilistic Sensitivity Analysis
Cost-effectiveness plane
In Fig. 2, each point represents a single output from each of 2000
Monte Carlo simulations in the C-E plane. The gure shows the
difference in LYS per person against the difference in cost per
person. All observations were in the northeast quadrant of the C-E
plane, thereby indicating that the screening program both
increased costs and improved effectiveness. In addition, the joint
density did not yield an incremental cost below US $30 in the C-E
plane. This implies that additional health benets of the screening
program require at least an additional cost of US $30 per person.
Cost-effectiveness acceptability curve
The CEAC for the breast cancer screening program is shown in
Fig. 3. The CEAC shows the probability that the screening
Table 4 Cost per woman of the screening for breast
cancer in Vietnam in 2008 US $.
*
Cost No-screening
scenario
Screening
scenario
Screening 0 3.06
Additional
tests
0 6.66
Annual
treatment
202 (2.59892.5) 202 (2.59892.5)

Costs were adjusted for ination to the year 2008.

Table 3 Cost estimates of the screening program for breast cancer (US $).
Activities Cost

Combined program
y
Breast cancer screening
1. Training courses 58,442.65 29,221.3
2. Workshop to develop program 9,686.63 4,843.3
3. Communication 113,653.75 56,826.9
4. Community supporter 17,758.82 8,879.4
5. Materials 209,473.30 104,736.6
6. Clinical breast examination 133,453.46 133,453.46
7. Specify for cervical screening (sampling, storing, dying, reading sample) 436,402.71
8. Supervision 20,483.18 10,241.6
9. Administrative 44,397.04 22,198.5
Total 1,043,751.53 370,401.1
Cost per person for breast cancer screening 3.06
Cost of additional tests to conrm breast cancer diagnosis
Cost of breast ultrasound 1.21
Cost of tumor biopsy 5.45
Cost per person for additional test 6.66
Sources: National Oncology Institutes (2011); Budget allocation for cancer screening in Thua Thien Hue province from 2008 to 2010; and Pub. L.
No.147/2007/TTLT-BYT-BTC.
25,28

Costs were adjusted for ination to the year 2008.

y
The combined screening program for cervical and breast cancer.
Table 5 Distribution for uncertainty parameters.
Uncertainty
parameters
Distribution Parameter estimates
Breast cancer
incidence
Beta (a,b) a: number of cases with
breast cancer
b: number of cases without
breast cancer
a b total number of
observations
Mortality
probability
Log normal
(lm, lv)
lm ln(mean)
lv ln(95% CI)
Cost Gamma (a,b) a m
2
/s
2
b s
2
/ m
95% CI, 95% condence interval; m, sample mean; s, sample
variance.
VA L U E I N H E A LT H R E G I O N A L I S S U E S 2 ( 2 0 1 3 ) 2 1 2 8 24
program is cost-effective for different monetary values placed on
LYS. The CEAC is derived from Fig. 2. A greater willingness-to-pay
(WTP) threshold for LYS increases the probability that the screen-
ing program is more cost-effective. A threshold of US $994.96 per
LYS implies that the probability that the screening program is
cost-effective is 45%. This probability reached 100% when the
WTP threshold was US $2300 or higher.
One-Way Sensitivity Analyses
The sensitivity analysis assessing the impact of various factors
on the cost-effectiveness of the screening program is presented
in a tornado diagram (Fig. 4). Changing the participation rate
from 100% to 70% increased the highest ICER value to US
$1,419.32 per life-year gained. Subsequently, increasing the cost
of the screening program by 30%, an earlier initiation of the
screening program, at age 35 years, and reducing the specicity
of CBE testing to 86% raised the ICER to US $1,292.03, US
$1,196.68, and US $ 1,124,15, respectively. An increase in the
duration of the screening program to age 60 years, however,
resulted in a decrease in ICER to US $974.21.
Discussion
The baseline analysis has shown that the implementation of an
annual screening with CBE for women aged between 40 and 55
years in Vietnam would enhance life-years gained. The impact of
the screening program of shifting to an earlier stage of breast
cancer at the point of detection resulted in longer life expectancy,
which is consistent with reports in the international literature
[6,10,29,36,37]. One reason why CBE has not been recommended as
a single technique for breast cancer screening in Western coun-
tries is due to its low sensitivity in detecting early breast cancer
[38]. Improving the skills of health care providers to perform CBE in
a screening program in pilot provinces through training programs
may improve the sensitivity of CBE in the early detection of breast
cancer in Vietnam, as recommended by previous studies [39,40].
The validity of CBE test from screening in Vietnam including
sensitivity and specicity, however, has not yet been assessed. A
further study is necessary, results of which will provide experience
in training skills for providers of screening programs.
An increase in the number of breast cancers detected and the
introduction of a nationwide screening program increased the
incremental costs incurred per woman by US $33.30. Thus, the
ICER of the screening program was estimated at US $994.96 per
LYS. This result is much lower than previous estimates in Japan
where the ICER for annual CBE alone was US $49,700 per LYS
in 1991 and US $40,385 per LYS in 2006. The authors concluded
that CBE was not an optimal screening technique for Japan
because it was less cost-effective compared with other alternatives
such as mammography or combined mammography and CBE
[29,36]. Unit costs used for each analysis account for the difference
in ICERs between our estimates and others. Japanese studies used
higher unit costs than those in our study; for example, the cost of
the screening program per person (excluding additional tests) was
US $131 in Japan compared with US $3.06 in our study [36]. A
similar comparison was also seen with work from India [6]. Using
the unit costs for India instead of those for The Netherlands
decreased the cost-effectiveness ratio sixfold in a study done in
India [6]. In addition, in Vietnam, combining breast cancer and
cervical cancer screening during the same visit contributed con-
siderably to lower the screening cost, and particularly costs for the
administrative and communication components of such costs.
The WHO suggests that the criterion for cost-effectiveness
should be less than three times the GDP per capita [41]. According
to these criteria, the CBE screening program in Vietnam is very
cost-effective as the ICER (US $994.96 per LYS) was less than the
GDP per capita of Vietnam, which in 2008 was US $1070 [11].
Further analysis of the CEAC revealed that an increase in the
WTP threshold from US $994.96 to US $2300 (less than three
times GDP per capita in 2008) would raise the cost-effectiveness
probability of the screening program from 45% to 100%. Con-
sequently, the CBE screening program can be considered an
appropriate option for implementation.
Extension of the duration of the screening period to 20 years
showed variation in the ICER estimates, but it remained within
acceptable cost-effectiveness thresholds. Although limits to the
number of older women (over 50 years) who participated in the
piloted program could have resulted in underestimates for mortal-
ity improvement among women between 40 and 60 years in the
screening scenario, this strategy was found to be the most cost-
effective to reduce breast cancer mortality among the alternatives
that were tested in the model. The evidence that breast cancer
incidence reached a peak in women aged 50 to 60 years in Vietnam
Table 6 Base-case results for the screening program vs. no screening program for breast cancer.
Cohort without
screening
Cohort with
screening
Change with screening
program
No. of breast cancers identied 82,144 79,726 2418
No. of deaths attributable to breast
cancer
53,311 44,317 8994
Life-years lost per person 11.1750629 11.1415901 0.0334728
Cost incurred per person (US $) 9.691 42.995 33.304
ICER (US $ per life-year saved) 994.96
ICER, incremental cost-effectiveness ratio.
Fig. 2 2000 Monte Carlo simulations of incremental cost-
effectiveness ratios plotted on a cost-effectiveness plane
comparing screening program vs. no screening program.
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[24] may explain this nding. With similar epidemiological char-
acteristics for breast cancer, a study in India also found that
screening between ages 40 and 60 years was more cost-effective
than between ages 50 and 70 years [6]. A screening strategy
combining cervical and breast cancer, however, has been imple-
mented in Vietnam. For cervical cancer, screening by Papanicolaou
test in women aged 30 to 49 years is recommended for the highest
reduction in cervical cancer incidence [1]. Initiation of screening
for women at age 35 years may be a more favorable alternative in
this situation, although it was less cost-effective than extending
screening to women aged 60 years (Fig. 4). The choice of appro-
priate screening policy for Vietnam will depend on not only
acceptability and affordability but also the objectives of the
program. Our study provides nancial evidence that can support
health decision makers to set priorities when limited resources
have to be distributed among competing health interventions.
Participation rates had the strongest inuence on the esti-
mated ICER. The ndings from the sensitivity analyses deter-
mined that the participation rate inuenced mainly the effect of
the screening program. Reducing the participation rate to 70%
resulted in an increase in the ICER to US $1419.32 per LYS,
between one and two times GDP per capita in Vietnam. A review
by Lam [38] of mammography screening in developed countries
found that screening of 70% or more of the target population was
required for an effective program. Our results suggest that the
screening program in Vietnam would still be cost-effective with a
participation rate of 70%. With the strong impact of this factor on
the ICER estimate, however, the mobilization of community
participation in a screening program is necessary. Breast health
education should be promoted in public as a factor to save
resources for the program.
Another issue is related to the specicity of CBE. Occurrence
of false-positive results may impose a nancial burden on payers
because all people who screen positive are offered more sophis-
ticated and expensive tests to conrm the diagnosis [42]. In this
study, we used the median specicity of CBE from a Japanese
study. Although our sensitivity analysis demonstrated that a
decrease in CBE specicity to 86% [36] increased the ICER to US
$1124.15, this gure is still regarded as cost-effective according
to WHO criteria. We also raised by 30% the costs of both the
Fig. 3 Cost-effectiveness acceptability curve for breast cancer screening program in Vietnam (health care payers
perspective).
Fig. 4 Result of univariate sensitivity analyses showing impact of key factors on ICERs for breast cancer screening program
in Vietnam.
VA L U E I N H E A LT H R E G I O N A L I S S U E S 2 ( 2 0 1 3 ) 2 1 2 8 26
screening program and additional tests to perform one-way
sensitivity analysis. The change reected not only the variation
of unit costs in different cities in the country but also expected
increases of unit costs in the future when the hospital fees will
change in public hospitals [28]. This result was still considered
cost-effective according to WHO recommendations. The screen-
ing program in Vietnam does not yet cover costs for additional
tests. This burden could reduce the effectiveness of the program
when a proportion of the positive women may not be able to
afford to conrm the diagnosis and thus may not get relevant
treatment. It was recommended that key prerequisites for the
screening program are that women must be able to access
appropriate and affordable diagnostic tests and treatment [40].
In the current context of Vietnam, the larger proportion of total
health expenditure is from household direct out-of-pocket pay-
ment at the time services are used [43]. The nancial burden of
treatment for the household would therefore increase with
increased demand for early detection of breast cancer due to
the screening program. Thus, to achieve effectiveness in reducing
mortality, the government should strengthen support policies to
ensure affordability of and accessibility to treatment for breast
cancer for all people. In Vietnam, expansion of health insurance
coverage and its package of benets should be regarded as the
rst solution to this problem.
Whereas screening by mammography has been considered the
only modality to reduce breast cancer mortality [40], recent studies
recommended using CBE screening as an alternative in developing
countries in which young age and advanced stages at presentation
are common characteristics for breast cancer, but in which the
resources for screening with mammography are limited
[8,10,37,44,45]. Our study contributes evidence for the benets of
CBE screening to reduce the burden of breast cancer in Vietnam.
Our study has some limitations that should be considered
when interpreting the ndings. First, we designed a simple model
based on the current screening situation in Vietnam, for which
there was uncertainty for some inputs. The screening program
for breast cancer with CBE has been implemented only as a pilot
in six big cities and provinces in Vietnam. The enrolment of the
target population in the program was limited, and selection bias
may result in overdetection for breast cancer; thus, the ICER
estimate was lower. A change in participation rate, however,
enhanced the evidence found from sensitivity analyses. Another
issue is that accurate determination of cancer stage distribution
was incomplete. We therefore applied reasonable assumptions
based on available data to estimate stage distribution and cost-
effectiveness of the screening program. Data on the cost of
additional tests were not available because the budget of the
NCCP did not support those activities. Screening test specicity
was based on data derived from other countries to enable us to
calculate these costs. The sensitivity analysis on change in
specicity, however, still showed that the screening program is
cost-effective in the Vietnamese context. Second, several poten-
tially important factors were ignored in our analysis, such as any
increase in the incidence rate of breast cancer, improvements in
survival due to treatment advances, and the proportion of
women with breast cancer who decline to have additional tests
because of household nancial constraints. Inclusion of these
factors might result in increases in ICERs of the screening
program due to increased cost of treatment of breast cancer or
decreased number of women who receive relevant treatment.
The base-case analysis, however, represented the main charac-
teristics of breast cancer in Vietnam at the time that the screen-
ing program was introduced. Third, the indirect costs for breast
cancer were also not included in this study. The inclusion of this
factor would possibly suggest that the screening program is more
highly cost-effective, because of the increase in cost savings from
reducing breast cancer mortality.
Conclusions
The CBE screening program for breast cancer for women aged 40
to 55 years in Vietnam is very cost-effective in light of the WHO
criteria. The results, however, suggested that changes in the
participation rate, earlier initiation of screening, an increase in
the costs of the screening program, and/or a decrease in the
specicity of CBE may strongly affect its cost-effectiveness.
Further research on the characteristics (sensitivity and specic-
ity) of CBE in Vietnam is needed. The results will assist health
policymakers in Vietnam to consider the nationwide rollout of
breast cancer screening with CBE. Our study demonstrated that
the CBE screening program could be used as an option to
reducing breast cancer mortality in countries with limited
resources in which breast cancer incidence is increasing.
Source of nancial support: These ndings are the result of
work supported by Graduate School, Khon Kaen University,
Thailand, and The Royal Netherlands Embassy in Hanoi, Viet-
nam, through the Project Center Of Excellence in Economic
Evaluation for Health.
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