Modeling the Cost-Effectiveness of Alternative Upper Age Limits for Breast Cancer Screening in England and Wales.
Currently in the United Kingdom, the National Health Service (NHS) Breast Screening Programme invites all women for triennial mammography between the ages of 47 and 73 years (the extension to 47-50 and 70-73 years is currently examined as part of a randomized controlled trial). The benefits and harms of screening in women 70 years and older, however, are less well documented.



The aim of this study was to examine whether extending screening to women older than 70 years would represent a cost-effective use of NHS resources and to identify the upper age limit at which screening mammography should be extended in England and Wales.



A mathematical model that allows the impact of screening policies on cancer diagnosis and subsequent management to be assessed was built. The model has two parts: a natural history model of the progression of breast cancer up to discovery and a postdiagnosis model of treatment, recurrence, and survival. The natural history model was calibrated to available data and compared against published literature. The management of breast cancer at diagnosis was taken from registry data and valued using official UK tariffs.



The model estimated that screening would lead to overdiagnosis in 6.2% of screen-detected women at the age of 72 years, increasing up to 37.9% at the age of 90 years. Under commonly quoted willingness-to-pay thresholds in the United Kingdom, our study suggests that an extension to screening up to the age of 78 years represents a cost-effective strategy.



This study provides encouraging findings to support the extension of the screening program to older ages and suggests that further extension of the UK NHS Breast Screening Programme up to age 78 years beyond the current upper age limit of 73 years could be potentially cost-effective according to current NHS willingness-to-pay thresholds.
School of Health and Related Research, Health Economics and Decision Science, University of Sheffield, Sheffield, UK. Electronic address: r.rafia@sheffield.ac.uk.
Rachid
R
Rafia
School of Health and Related Research, Health Economics and Decision Science, University of Sheffield, Sheffield, UK.
Alan
A
Brennan
Division of Health Sciences, Warwick Medical School, Coventry, UK.
Jason
J
Madan
Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK.
Karen
K
Collins
Brighton and Sussex Medical School, University of Sussex, Brighton, UK.
Malcolm W R
MW
Reed
Breast Screening QA Reference Centre, West Midlands Cancer Intelligence Unit, Public Health Building, The University of Birmingham, Birmingham, UK.
Gill
G
Lawrence
Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
Thompson
T
Robinson
Eastern Cancer Registration and Information Centre (ECRIC), Unit C, Cambridge, UK.
David
D
Greenberg
Academic Unit of Surgical Oncology, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK.
Lynda
L
Wyld
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000175:diagnosis / Q000191:economics* / Q000628:therapy; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer / Q000191:economics; D004739:England; D005260:Female; D006291:Health Policy / Q000191:economics*; D006801:Humans; D008327:Mammography / Q000191:economics*; D000069342:Medical Overuse; D009010:Monte Carlo Method; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D013222:State Medicine; D014852:Wales
cost-effectiveness; elderly; mammography; screening