The Brrast ( 1992) 1, I69- I72

Review article

Cost-effectiveness of breast cancer screening

N. M. Fraser* and P. R. Clarke?

*Department qf Social Policy, Universio of Edinburgh. f Department of Economics, Heriot- Watt Universig.
Edinburgh. UK

S I/ MM A R Y. This review reports progress in cost-effectiveness studies in relation to breast cancer screening,
and identifies a number of problems which have not been fully solved. One of these is the use of data from
different countries. Caution is required when interpreting the results in such circumstances as there are
clinical and socio-economic variations which are not well understood. Care must be taken when extrapolating
from a trial to a national screening programme because of the additional costs of implementing a national
screening programme (e.g. extra qualified staff are required) and there are the differences generated when
replicating a research based trial in the form of a service.
Attention is drawn to the reliance of cost-effectiveness analysis on clinical results, especially in the form of
years of life saved, which in principle depend on lifetime follow up, though this is not yet available from trials
of breast cancer screening. The use of measures of morbidity as well as mortality is supported but the
variability of estimates of these weights is acknowledged. This is an area for further research, especially
because of the recognition of potentially significant psychological aspects in breast cancer screening and
treatment. A further point is that any national screening programme does not take place in isolation and the
indirect consequence on the demand side are likely in themselves to have resource implications. An example of
this is the stimulus to the demand for screening by those outside the proposed screening population.

INTRODUCTION life saved (QALY). Studies using QALYs are often

referred to as cost-utility studies (e.g. in the Forrest
Economic evaluation has been defined as the Report) but cost-effectiveness seems to us a good
comparative analysis of alternative courses of action in generic name for all the studies reviewed here. Cost per
terms of both costs and consequences. It is widely years of life saved and cost per QALY measures can be
recognised that mass screening needs to balance costs compared for different forms of a given health pro-
against benefits. Economic evaluation builds on gramme (e.g. different screening regimes) and for
medical evaluation and depends crucially upon it for different health investments. The Forrest Report3
estimates of effectiveness. includes such a QALY league table for comparison of
breast cancer screening with other health investments.

What is cost-effectiveness?
Policy effectiveness is firstly a matter of improving Methodology
health (clinical effectiveness). But given limited CEA is a tool for decision taking in relation to
resources this needs to be extended with a measurement specific programmes such as the introduction of a
of cost and with a measure of outcome presented in national screening programme (for a general intro-
standardised health units for comparisons with other duction to CEA methodology see reference). One
policies. Cost-effectiveness analysis (CEA) is this approach to CEA is to base the estimates on a specific
extension. The health outcome measures commonly medical trial. The advantage of this approach is that it
used are years of life saved and quality-adjusted years of reduces the problem of data inconsistency between the
screened and control groups. What it does not directly
allow is evaluation of variation in the screening inputs
Correspondence to: Mr N. Fraser, Department of Social Policy, Adam
Ferguson Building, University of Edinburgh, George Square.
which are not part of the trial. This problem can be
Edinburgh, EH8 YLL, UK overcome by modelling the data but even here the value

169
of the parameters used should be based on trial data. The
foremost example of modelling in relation to breast
cancer screening is the Dutch model.4 This derives, from
analysis of the results of screening trials, assumptions
about a) the average duration of the preclinical screen
detectable stage, b) the sensitivity of mammography,
and c) the reduction in probability of death for small
sized, early-detected cancers. These are used to simulate
the effectiveness of alternative designs for a national
screening programme for Holland. Another modelling
approach is that of Knox. It can be argued that the CEA
in the Forrest Report3 paid insufficient attention to the
build-up costs for a national programme, e.g. the
training of radiologists6
Two early articles use the following useful framework
for a cost-effectiveness analysis.7v8Costs and benefits are
identified for each of the four screening categories, true
negatives, true positives, false negatives and false
positives, and compared with three conventional man-
agement categories, conventional cancers, worried
wells, and unworried wells. However when applied to a
screening programme it is important also to consider the
health outcomes and costs for non-attenders. These have
the same categories as conventional management but
are part of the screening population. This is widely
recognised in medical evaluation.
Basic results in different studies
This review will take as its starting point the Forrest
Report3 This report included an economic appraisal of
the screening programme the committee recommended
for Britain. The report presented estimates of cost per
year of life saved, and cost per QALY. The costing data
was obtained from the Edinburgh trial and the medical
effectiveness data was extracted from two sources, the
HIP Trial and the Swedish Two Counties Trial. The
Forrest Report3 recommended a screening programme of
once every three years for women of 50-65 years of age,
of which the estimated discounted cost of year of life
saved was &3044 and cost per QALY was &3309 (at
1983/4 prices).
Because of different assumptions in different studies
it is difficult to make comparisons, so what is presented
here is at best illustrative. We begin with cost per screen.
The Forrest Report3 gives E11.66 per screen at 1983/4
prices for single-view mammography. The final
Edinburgh ReportI gives g14.87 (approx. US$26) at
1989 prices for this type of screen. The Dutch estimateI
is US$35.50 including regional and central costs for
invitations, training and quality control ($30.60 is for the
screening unit and mammogram reading). An
Australian14 cost per screen is US$66 (including
recruitment of women) and American $75.
Adjusting the Forrest Report3 figure for cost per life-
year saved to 1989 prices gives &4262. Our estimate*
for the same screening regime but using the Edinburgh
trial6 outcome rather than the HIP and Two Counties
Trial is g8638. One model estimate for Holland17, with a
similar screening regime but based on the average
results of the Two Counties and Maim@ trials, is
US$3235. Contributory factors to their superior cost-
effectiveness are the estimate of benefits over a longer
period, with savings in advanced disease costs, plus a
high screening response rate.
Assumptions in CEA studies
We begin with a factor which makes a significant
difference to CEA measures. The longer the period over
which the benefits are estimated the lower the costs per
year life saved or per QALY. We initially measured the
benefits of the Edinburgh trial over 7 years (the basis of
the first clinical outcome measure). The Forrest
Report3 extrapolated the data over 15 years and others
have extended the analysis over an even longer period.
The general difficulty is that there is a lack of hard data
on which to base these estimates, but in principle long
term benefits should be included. They can have a big
effect if the heavy costs of terminal care are prevented,
even though discounting reduces the contribution of far-
future effects. To give an example of the consequences
of different time periods over which the benefits are
measured, we can compare the Forrest Report3 results
over 15 years, g.3044 per life year gained, with what
their results would have been over 7 years, &I5 958 per
year of life saved. The DutchI get even lower figures
(US$3235) by extending their analysis well beyond 15
years. For criticism of estimating lifespan effects before
the evidence is available, see, for example, Rodgers.lY
The paragraph above on cost per life-year saved in
different studies illustrates the effect of using data from
different trials. Later results have not been as favourable
to screening as the H.I.P. and the Swedish Two County
Trial used for the Forrest Report3 De Koning et a1.17,in
their Figure 3, give a range of CEA results for differing
trials. It is still too early to say which trials give the best
evidence for evaluating a national programme, and care
is needed in international transfer of evidence, for
example because of differing breast cancer incidence
rates, and differences in screening take-up rates.
What is the effect of taking into account quality of life
as well as life years gained? A thorough study of this is
incorporated in the Dutch model.* This paper firstly
mapped the consequences of disease and treatment in
their different phases by a literature review, secondly
assigned values to these phases by sampling experts in
breast cancer and public health, and thirdly, multiplied
values by the duration of the different phases and the
number of women to be expected so that quality-
adjusted life-years with and without the programme
could be compared. As is often the case in these
exercises, the variation in values people give to different
health-states was considerable. Using median values, the
quality-adjustment weightings range from .99 for the
screening phase to as low as .29 for those patients who

have terminal advanced disease. The study found that
adjustment for quality of life effects made only a minor
difference. Although earlier detection means more
women for diagnosis and treatment this is balanced by
fewer women having the low quality of life associated
with advanced disease and its treatment. Preliminary
results from an Australian study suggest they may reach
different conclusions.2 They have a low quality of life
figure for the claimed 25% of women with cancer who
suffer mental ill-health. But this initial paper only deals
with true positives so that it is quite incomplete.
Economists have argued that it is not only the service
costs which should be estimated and included but also the
costs to patients. There have been a number of estimates
of the cost to women being screened (e.g. &2.83 per visit
at 198314 prices in Edinburgh). As a percentage of the
service cost per screen these add on 24% in
Edinburgh,,. 1lS%-25% in Guildfordz2, 10.75% in
Holland. Because non-service costs are not included in
cost effectiveness measures for other health interventions
these data are often ignored in league tables.
Health projects generate costs and benefits at different
times and the value of these costs and benefits depend in
part on these times. People have preferences for benefits
sooner rather than later, and costs later rather than
sooner. So as a consequence it is usually argued that
future costs and benefits have to be discounted back to
the present. Discounting implies that life years further
away from the present are worth less. There is some
discussion as to whether health benefits (i.e. non-
monetary benefits) should be discounted at all,2.2deven
for the sake of consistency with the measurement of
monetary costs and benefits. The argument is that life is
intrinsically different. This issue is currently being
vigorously debated in the health economics
literature.4.5 Figures of cost per life-year and cost per
QALY presented in this review follow the practice in
CEA reports in this field of discounting both monetary
and non-monetary costs and benefits. A change of
practice would involve small changes in cost per QALY
league tables, though it does not look as though breast
cancer screenings position would be much affected.j
The discount rate used in studies in this field has tended
to be 5%, though the current UK Government rate is
6%.
Other aspects of cost analysis
Evaluations identify the incremental costs and benefits
i.e. those which are generated as a result of a decision to
change policy in some area. These include direct and
indirect effects. One example of the latter is when a
screening programme generates demand for screening
from those outside the age range for which it is
recommended.h,7 Another aspect to be considered is
that this approach usually assumes implicitly no change
in the control populations costs and benefits. This
assumption in a society which has access to increasing
Cost-effectiveness of breast cancer screening 17 1
amount of medical information may be difficult to
uphold as there will be increasing demand for breast
examinations even if there is no national screening
programme.
Different studies have used different procedures for
deriving costs. Basically either they can be estimated
from observing actual resources used. both labour and
materials, or they can be extracted from the expenditure
records and determined on an average basis. The latter
approach allows no mixing of the modalities of
screening, whereas the former approach enables specific
modality costing estimates to be made.
How important are diagnostic and treatment costs to
the cost-effectiveness of breast cancer screening? Early
work, apart from that by Gravelle et aLx did not follow
up treatment cost7.3 Gravelle et al not only included
treatment cost, but also non-breast-cancer treatment cost
in life-years gained. They calculated a very high post-
screening cost, but this was not so much treatment costs
as costs of diagnosis with high false-positive rates. Our
work based on the Edinburgh trial emphasised primary
treatment costs. We found net diagnostic and treatment
costs added 27% to total screening costs in the case of
prevalence screens, but only 6% in the case of follow-on
mammographic screens. The Dutch included the cost
of advanced disease and found this made a lot of
difference, so that overall screening costs are reduced by
22.3%. even with a 5% discount rate (a screening
programme costing US$300million generated an overall
change in costs of $233million).
Results on policy options
Early work on the cost-effectiveness of breast cancer
concentrated on the effect of different modalities.x~2.5
Results can be presented in terms of the marginal cost-
effectiveness of adding mammography to physical
examination or vice versa. Using the Edinburgh trial
results welZ found adding physical examination to
mammography much less cost-effective than the other
way round, although EddysI results support the
provision of physical examination. Latter work tends to
use one view mammography because of the success of
the Swedish trial.
Two important policy issues which economic analysis
illuminates are the choice of age groups for screening,
and the choice of screening frequency. The table from
the Dutch work, gives a good illustration of how a
modelling approach can help with these issues. It
confirms, for example, the low cost effectiveness found
for screening women aged under SO by the Forrest
Report3 The Dutch also use the table to support the
Forrest Report3 recommendation that screening once
every three years is an efficient frequency choice,
though they go on to point out that a two yearly
frequency may be a better use of resources than many
other health investments. This conclusion is based on
the calculation of the marginal cost effectiveness of
172 The Breast

Il. Tab&r L, Gad A, Holmberg L H, Ljunquist U, Fagarberg C J G,

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