Cost-effectiveness of breast cancer screening in women on dialysis.
BACKGROUND
Breast cancer screening is recommended for women 50 years and older in most developed countries. Women on dialysis therapy have a risk of acquiring breast cancer similar to that for other women, but a greater all-cause mortality rate because of mortality from other competing causes. It is uncertain whether routine screening is cost-effective in women on dialysis therapy. In this study, we determine the costs and health outcomes of annual mammographic breast cancer screening in women on dialysis therapy.


METHODS
We performed a cost-effectiveness analysis. Sensitivity and scenario analyses were performed to assess uncertainties in the model's parameter estimates. BASE CASE: A cohort (n = 1,000) of women on dialysis therapy aged 50 to 69 years in Australia. MODEL, PERSPECTIVE, AND TIME FRAME: A deterministic Markov model was developed from the perspective of a health care payer. Patients were followed up over their life time.


METHODS
We compared a cohort of women who underwent annual mammography with a cohort that did not.


RESULTS
Life-years saved (LYS), costs, and incremental cost-effectiveness ratio (ICER).


RESULTS
Average costs for a program of annual screening for a woman on dialysis therapy were $4,805 over 30 years. Incremental costs of screening were $403, and benefits were 0.0037 LYS. Five breast cancer deaths occurred in the screened arm and 6 breast cancer deaths occurred in the unscreened arm, a difference of 1 breast cancer averted by screening, with an estimated ICER of $109,852/LYS. The absolute reduction in breast cancer mortality was 0.1%, with a net gain in life expectancy of 1.3 days. The ICER was strongly dependent on age, with the most favorable ICER approximately $100,000/LYS at age 45 years.


CONCLUSIONS
Costs and clinical data were obtained from the nonindigenous Australian population and may not be generalizable to African Americans on dialysis therapy and indigenous populations from other countries.


CONCLUSIONS
Using the most optimistic assumptions, survival gains expected from screening for breast cancer in women on dialysis therapy are very small. Annual population breast cancer screening should not be recommended for all women on dialysis therapy, but should be an individual decision between the patient and health care provider.
Wong
Germaine
G
NHMRC Centre for Clinical Research Excellence in Renal Medicine, Children's Hospital at Westmead, Westmead, NSW, Australia. germainw@chw.edu.au
Howard
Kirsten
K
Chapman
Jeremy R
JR
Craig
Jonathan C
JC
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000191:economics*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008327:Mammography / Q000191:economics*; D008390:Markov Chains; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D006435:Renal Dialysis; D012680:Sensitivity and Specificity