title: Retrospective cost-effectiveness analysis of screening mammography.
abstract: BACKGROUND
  Many guidelines recommend screening mammography every 1-2 years for women older than 40 years; more than 70% of women now participate in routine screening. No studies have examined the societal impact of screening practices over the past decade in the United States on costs and quality-adjusted life-years (QALYs). We performed a retrospective cost-effectiveness analysis comparing actual and alternative screening mammography scenarios.
  
  
  METHODS
  We used a discrete-event simulation model of breast cancer epidemiology to estimate the costs and the number of QALYs that were associated with observed screening mammography patterns in the United States from 1990 to 2000 for women aged 40 years or older. We also estimated costs and QALYS for no screening and for 64 alternative screening scenarios. Incremental cost-effectiveness ratios were computed. Sensitivity analyses were performed on key parameters.
  
  
  RESULTS
  Actual U.S. screening patterns from 1990 to 2000 accrued 947.5 million QALYs and cost $166 billion over the lifetimes of the screened women, resulting in a gain of 1.7 million QALYs for an additional cost of $62.5 billion compared with no screening. Among those polices that were not dominated--i.e., for which no alternative existed that produced more QALYs for lower costs--screening all women aged 40-80 years annually per some U.S. guidelines was the most expensive option, costing $58,000 per additional QALY gained compared with the next most costly alternative, screening all women aged 45-80 years annually. Many alternative screening scenarios generated more QALYs for less cost (with savings up to $6 billion) than actual screening patterns over the study period. Sensitivity analysis showed that conclusions about the cost-effectiveness of screening mammography policies were highly sensitive to small, short-term detrimental effects on quality of life from the screening test itself.
  
  
  CONCLUSIONS
  Choosing among the efficient policies to guide current screening recommendations requires consideration of costs to promote participation in screening and measurement of acute quality-of-life effects of mammography.
authors.affiliation: Center for Risk Analysis, Harvard School of Public Health, Boston, MA 02115, USA. nstout@hsph.harvard.edu
authors.forename: Natasha K
authors.initials: NK
authors.lastname: Stout
authors.forename: Marjorie A
authors.initials: MA
authors.lastname: Rosenberg
authors.forename: Amy
authors.initials: A
authors.lastname: Trentham-Dietz
authors.forename: Maureen A
authors.initials: MA
authors.lastname: Smith
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Robinson
authors.forename: Dennis G
authors.initials: DG
authors.lastname: Fryback
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000191:economics* / Q000401:mortality; D003362:Cost-Benefit Analysis; D004180:Direct Service Costs / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008327:Mammography / Q000009:adverse effects / Q000191:economics*; D008403:Mass Screening / Q000009:adverse effects / Q000191:economics* / Q000379:methods; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014481:United States / Q000453:epidemiology; D016387:Women's Health