Toward optimal screening strategies for older women. Costs, benefits, and harms of breast cancer screening by age, biology, and health status.
BACKGROUND
Optimal ages of breast cancer screening cessation remain uncertain.


OBJECTIVE
To evaluate screening policies based on age and quartiles of life expectancy (LE).


METHODS
We used a stochastic model with proxies of age-dependent biology to evaluate the incremental U.S. societal costs and benefits of biennial screening from age 50 until age 70, 79, or lifetime.


METHODS
Discounted incremental costs per life years saved (LYS).


RESULTS
Lifetime screening is expensive (151,434 dollars per LYS) if women have treatment and survival comparable to clinical trials (idealized); stopping at age 79 costs 82,063 dollars per LYS. This latter result corresponds to costs associated with an LE of 9.5 years at age 79, a value expected for 75% of 79-year-olds, about 50% of 80-year-olds, and 25% of 85-year-olds. Using actual treatment and survival patterns, screening benefits are greater, and lifetime screening of all women might be considered (114,905 dollars per LYS), especially for women in the top 25% of LE for their age (50,643 dollars per LYS, life expectancy of approximately 7 years at age 90).


CONCLUSIONS
If all women receive idealized treatment, the benefits of mammography beyond age 79 are too low relative to their costs to justify continued screening. However, if treatment is not ideal, extending screening beyond age 79 could be considered, especially for women in the top 25% of life expectancy for their age.
Department of Oncology, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA. tdm3@georgetown.edu
Jeanne S
JS
Mandelblatt
Clyde B
CB
Schechter
K Robin
KR
Yabroff
William
W
Lawrence
James
J
Dignam
Martine
M
Extermann
Sarah
S
Fox
Gretchen
G
Orosz
Rebecca
R
Silliman
Jennifer
J
Cullen
Lodovico
L
Balducci
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000453:epidemiology / Q000517:prevention & control; D003362:Cost-Benefit Analysis; D018450:Disease Progression; D005260:Female; D006801:Humans; D008017:Life Expectancy; D008327:Mammography / Q000191:economics*; D008403:Mass Screening / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D008875:Middle Aged; D017059:Models, Econometric; D009010:Monte Carlo Method; D009367:Neoplasm Staging; D012680:Sensitivity and Specificity; D013269:Stochastic Processes; D016019:Survival Analysis; D026712:Value of Life
D014408:Biomarkers, Tumor