title: Cost-effectiveness analysis of breast cancer control interventions in Peru.
abstract: OBJECTIVE
  In Peru, a country with constrained health resources, breast cancer control is characterized by late stage treatment and poor survival. To support breast cancer control in Peru, this study aims to determine the cost-effectiveness of different breast cancer control interventions relevant for the Peruvian context.
  
  
  METHODS
  We performed a cost-effectiveness analysis (CEA) according to WHO-CHOICE guidelines, from a healthcare perspective. Different screening, early detection, palliative, and treatment interventions were evaluated using mathematical modeling. Effectiveness estimates were based on observational studies, modeling, and on information from Instituto Nacional de Enfermedades Neoplásicas (INEN). Resource utilizations and unit costs were based on estimates from INEN and observational studies. Cost-effectiveness estimates are in 2012 United States dollars (US$) per disability adjusted life year (DALY) averted.
  
  
  RESULTS
  The current breast cancer program in Peru ($8,426 per DALY averted) could be improved through implementing triennial or biennial screening strategies. These strategies seem the most cost-effective in Peru, particularly when mobile mammography is applied (from $4,125 per DALY averted), or when both CBE screening and mammography screening are combined (from $4,239 per DALY averted). Triennially, these interventions costs between $63 million and $72 million per year. Late stage treatment, trastuzumab therapy and annual screening strategies are the least cost-effective.
  
  
  CONCLUSIONS
  Our analysis suggests that breast cancer control in Peru should be oriented towards early detection through combining fixed and mobile mammography screening (age 45-69) triennially. However, a phased introduction of triennial CBE screening (age 40-69) with upfront FNA in non-urban settings, and both CBE (age 40-49) and fixed mammography screening (age 50-69) in urban settings, seems a more feasible option and is also cost-effective. The implementation of this intervention is only meaningful if awareness raising, diagnostic, referral, treatment and basic palliative services are simultaneously improved, and if financial and organizational barriers to these services are reduced.
authors.affiliation: Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands.
authors.forename: Sten G
authors.initials: SG
authors.lastname: Zelle
authors.affiliation: Directorio Médico del INEN, Instituto Nacional de Enfermedades Neoplásicas (INEN), Lima, Peru.
authors.forename: Tatiana
authors.initials: T
authors.lastname: Vidaurre
authors.affiliation: Directorio Médico del INEN, Instituto Nacional de Enfermedades Neoplásicas (INEN), Lima, Peru.
authors.forename: Julio E
authors.initials: JE
authors.lastname: Abugattas
authors.affiliation: Directorio Ejecutivo de Promoción de la Salud, Prevención y Control Nacional del Cáncer, Instituto Nacional de Enfermedades Neoplásicas (INEN), Lima, Peru.
authors.forename: Javier E
authors.initials: JE
authors.lastname: Manrique
authors.affiliation: Departamento de Radioterapia, Instituto Nacional de Enfermedades Neoplásicas (INEN), Lima, Peru ; Directorio Médico del INEN, Instituto Nacional de Enfermedades Neoplásicas (INEN), Lima, Peru.
authors.forename: Gustavo
authors.initials: G
authors.lastname: Sarria
authors.affiliation: Programa Comunitario de Salud Mamaria, PATH a catalyst for global health, Seattle, Washington, United States of America.
authors.forename: José
authors.initials: J
authors.lastname: Jeronimo
authors.affiliation: Centro de Investigación, Universidad Del Pacifico, Lima, Peru.
authors.forename: Janice N
authors.initials: JN
authors.lastname: Seinfeld
authors.affiliation: Costs, Effectiveness, Expenditure and Priority Setting, World Health Organization, Geneva, Switzerland.
authors.forename: Jeremy A
authors.initials: JA
authors.lastname: Lauer
authors.affiliation: Cancer Control, Management of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland.
authors.forename: Cecilia R
authors.initials: CR
authors.lastname: Sepulveda
authors.affiliation: Dirección General de Salud de las Personas, Ministerio de Salud (MINSA), Lima, Peru.
authors.forename: Diego
authors.initials: D
authors.lastname: Venegas
authors.affiliation: Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands.
authors.forename: Rob
authors.initials: R
authors.lastname: Baltussen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control*; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008875:Middle Aged; D008962:Models, Theoretical; D010568:Peru / Q000453:epidemiology; D055815:Young Adult