title: Comparative effectiveness of combined digital mammography and tomosynthesis screening for women with dense breasts.
abstract: OBJECTIVE
  To evaluate the effectiveness of combined biennial digital mammography and tomosynthesis screening, compared with biennial digital mammography screening alone, among women with dense breasts.
  
  
  METHODS
  An established, discrete-event breast cancer simulation model was used to estimate the comparative clinical effectiveness and cost-effectiveness of biennial screening with both digital mammography and tomosynthesis versus digital mammography alone among U.S. women aged 50-74 years with dense breasts from a federal payer perspective and a lifetime horizon. Input values were estimated for test performance, costs, and health state utilities from the National Cancer Institute Breast Cancer Surveillance Consortium, Medicare reimbursement rates, and medical literature. Sensitivity analyses were performed to determine the implications of varying key model parameters, including combined screening sensitivity and specificity, transient utility decrement of diagnostic work-up, and additional cost of tomosynthesis.
  
  
  RESULTS
  For the base-case analysis, the incremental cost per quality-adjusted life year gained by adding tomosynthesis to digital mammography screening was $53 893. An additional 0.5 deaths were averted and 405 false-positive findings avoided per 1000 women after 12 rounds of screening. Combined screening remained cost-effective (less than $100 000 per quality-adjusted life year gained) over a wide range of incremental improvements in test performance. Overall, cost-effectiveness was most sensitive to the additional cost of tomosynthesis.
  
  
  CONCLUSIONS
  Biennial combined digital mammography and tomosynthesis screening for U.S. women aged 50-74 years with dense breasts is likely to be cost-effective if priced appropriately (up to $226 for combined examinations vs $139 for digital mammography alone) and if reported interpretive performance metrics of improved specificity with tomosynthesis are met in routine practice.
authors.affiliation: From the Depts of Radiology (C.I.L., J.G.J., C.D.L.), Health Services (C.I.L., J.G.J., S.D.R.), and Medicine (S.D.R.), Univ of Washington, 825 Eastlake Ave E, G3-200, Seattle, WA 98109-1023; Hutchinson Inst for Cancer Outcomes Research, Public Health Sciences Div, Fred Hutchinson Cancer Research Ctr, Seattle, Wash (C.I.L., S.D.R., C.D.L.); Dept of Industrial and Systems Engineering, Univ of Wisconsin, Madison, Wis (M.C., O.A.); Dept of Surgery and Office of Health Promotion Research, Univ of Vermont, Burlington, Vt (B.L.S.); Dept of Community & Family Medicine, Dartmouth Inst for Health Policy & Clinical Practice, and Norris Cotton Cancer Ctr, Geisel School of Medicine, Dartmouth Univ, Dartmouth, NH (A.N.A.T.); Dept of Public Health Sciences, Univ of California-Davis, Davis, Calif (D.L.M.); Group Health Research Inst, Seattle, Wash (D.L.M.); Dept of Medicine and Dept of Epidemiology and Biostatistics, General Internal Medicine Section, Dept of Veterans Affairs, Univ of California-San Francisco, San Francisco, Calif (K.K.); and Dept of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Inst, Boston, Mass (N.K.S.).
authors.forename: Christoph I
authors.initials: CI
authors.lastname: Lee
authors.forename: Mucahit
authors.initials: M
authors.lastname: Cevik
authors.forename: Oguzhan
authors.initials: O
authors.lastname: Alagoz
authors.forename: Brian L
authors.initials: BL
authors.lastname: Sprague
authors.forename: Anna N A
authors.initials: AN
authors.lastname: Tosteson
authors.forename: Diana L
authors.initials: DL
authors.lastname: Miglioretti
authors.forename: Karla
authors.initials: K
authors.lastname: Kerlikowske
authors.forename: Natasha K
authors.initials: NK
authors.lastname: Stout
authors.forename: Jeffrey G
authors.initials: JG
authors.lastname: Jarvik
authors.forename: Scott D
authors.initials: SD
authors.lastname: Ramsey
authors.forename: Constance D
authors.initials: CD
authors.lastname: Lehman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000000981:diagnostic imaging*; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer / Q000191:economics / Q000379:methods*; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000191:economics; D008327:Mammography / Q000191:economics; D008875:Middle Aged; D011856:Radiographic Image Enhancement / Q000191:economics