How risk-based breast cancer screening could cut costs, reduce overdiagnosis

Breast cancer screening programs could reduce both costs and overdiagnosis by focusing on at-risk women, according to a new study published by JAMA Oncology.

“Identifying risk-stratified screening strategies with a more favorable ratio of overdiagnoses to breast cancer deaths prevented would improve the quality of life of women and save resources,” wrote author Nora Pashayan, MD, PhD, of University College London, and colleagues.

The authors examined a hypothetical patient cohort of 364,500 50-year-old women who underwent follow-up screening until the age of 85. They compared the impact of three models: one that included no screening, one that included age-based screening and one that included risk-stratified screening, offering certain at-risk women screening every three years until the age of 69.

Overall, as the risk-stratified model’s risk threshold became lower, the cost of the program grew larger. But when the model used a risk threshold of the 35th percentile, it resulted in no additional quality-adjusted life-years (QALYs) gained. The risk-stratified model, using a risk threshold of the 70th percentile, had the highest net monetary benefit (NMB) with a 72-percent probability of being cost-effective.

“The relationship between the cost of the program and the QALYs gained shows diminishing return with offering screening to women at lower risk,” Pashayan and colleagues wrote. “The lower the risk threshold, i.e., the larger the proportion of women offered screening, the higher would be the cost of the program, while the gain in QALYs would flatten off after a certain risk threshold. Lowering the risk threshold for screening would increase overdiagnosis to a greater extent than it would reduce breast cancer deaths.”

The authors added that for every 10,000 50-year-old women screened using an age-based screening model, they estimate “52 deaths from breast cancer will be prevented and 105 patients with breast cancer will be overdiagnosed.”

Pashayan et al. concluded by pointing out some potential hurdles leaders may face if they consider going forward with a risk-based screening program.

“Implementation of a risk-based screening program raises several challenges,” the authors wrote. “These include (1) ensuring that genetic testing for stratification and eligibility for screening are acceptable to the public and the health care professionals; (2) preparing and training the workforce; (3) ensuring equitable access; and (4) having regulatory approvals.”

Prior Radiology Business coverage of risk-based breast cancer screening is available here.