Disability-Adjusted Life Years Averted Versus Quality-Adjusted Life Years Gained: A Model Analysis for Breast Cancer Screening.

OBJECTIVES: To quantify the impact of mammography-based screening on the quality of life, disability-adjusted life years (DALYs) averted or quality-adjusted life years (QALYs) gained can be used. We aimed to assess whether the use of DALYs averted or QALYs gained will lead to different cost-effective screening strategies. METHODS: Using the microsimulation model MISCAN, we simulated different breast cancer screening strategies varying in starting age (starting at 45, 47, and 50 years), stopping age (stopping at 69, 72, and 74 years), and frequency (annual [A], biennial [B], combination of both [A + B], and triennial [T]). In total, we defined 24 different breast cancer screening strategies, including no screening as a reference strategy. We calculated incremental cost-effectiveness ratios (ICERs) and compared which strategies were on the efficiency frontiers for DALYs and QALYs. RESULTS: Breast cancer screening averted between 46.00 and 105.58 DALYs and gained between 28.69 and 64.50 QALYs per 1000 women. For DALYs there were 5 strategies on the efficiency frontier (T50-69, T50-74, T45-74, B45-74, and A45-74). The same strategies plus one (B45-72) were on the efficiency frontier for QALYs. CONCLUSIONS: Using DALYs averted instead of QALYs gained to assess the effects on quality of life from breast cancer screening in the Dutch population yields differences in ICERs, but almost the same strategies were on the efficiency frontiers. Whether the choice in outcome measure leads to a difference in optimal policy depends on the cost-effectiveness threshold.

Availability of data for cost-effectiveness comparison of child vision and hearing screening programmes.

OBJECTIVE: For cost-effectiveness comparison of child vision and hearing screening programmes, methods and data should be available. We assessed the current state of data collection and its availability in Europe. METHODS: The EUSCREEN Questionnaire, conducted in 2017-2018, assessed paediatric vision and hearing screening programmes in 45 countries in Europe. For the current study, its items on data collection, monitoring and evaluation, and six of eleven items essential for cost-effectiveness analysis: prevalence, sensitivity, specificity, coverage, attendance and loss to follow-up, were reappraised with an additional questionnaire. RESULTS: The practice of data collection in vision screening was reported in 36% (N = 42) of countries and in hearing screening in 81% (N = 43); collected data were published in 12% and 35%, respectively. Procedures for quality assurance in vision screening were reported in 19% and in hearing screening in 26%, research of screening effectiveness in 43% and 47%, whereas cost-effectiveness analysis was performed in 12% for both. Data on prevalence of amblyopia were reported in 40% and of hearing loss in 77%, on sensitivity of screening tests in 17% and 14%, on their specificity in 19% and 21%, on coverage of screening in 40% and 84%, on attendance in 21% and 37%, and on loss to follow-up in 12% and 40%, respectively. CONCLUSIONS: Data collection is insufficient in hearing screening and even more so in vision screening: data essential for cost-effectiveness comparison could not be reported from most countries. When collection takes place, this is mostly at a local level for quality assurance or accountability, and data are often not accessible. The resulting inability to compare cost-effectiveness among screening programmes perpetuates their diversity and inefficiency.

Cost-effectiveness of multiparametric magnetic resonance imaging and MRI-guided biopsy in a population-based prostate cancer screening setting using a micro-simulation model.

BACKGROUND: The introduction of multiparametric magnetic resonance imaging (mpMRI) and MRI-guided biopsy has improved the diagnosis of prostate cancer. However, it remains uncertain whether it is cost-effective, especially in a population-based screening strategy. METHODS: We used a micro-simulation model to assess the cost-effectiveness of an MRI-based prostate cancer screening in comparison to the classical prostate-specific antigen (PSA) screening, at a population level. The test sensitivity parameters for the mpMRI and MRI-guided biopsy, grade misclassification rates, utility estimates, and the unit costs of different interventions were obtained from literature. We assumed the same screening attendance rate and biopsy compliance rate for both strategies. A probabilistic sensitivity analysis, consisting of 1000 model runs, was performed to estimate a mean incremental cost-effectiveness ratio (ICER) and assess uncertainty. A €20,000 willingness-to-pay (WTP) threshold per quality-adjusted life year (QALY) gained, and a discounting rate of 3.5% was considered in the analysis. RESULTS: The MRI-based screening improved the life-years (LY) and QALYs gained by 3.5 and 3, respectively, in comparison to the classical screening pathway. Based on the probabilistic sensitivity analyses, the MRI screening pathway leads to total discounted mean incremental costs of €15,413 (95% confidence interval (CI) of €14,556-€16,272) compared to the classical screening pathway. The corresponding discounted mean incremental QALYs gained was 1.36 (95% CI of 1.31-1.40), resulting in a mean ICER of €11,355 per QALY gained. At a WTP threshold of €20,000, the MRI screening pathway has about 84% chance to be more cost-effective than the classical screening pathway. CONCLUSIONS: For triennial screening from age 55-64, incorporation of mpMRI as a reflex test after a positive PSA test result with a subsequent MRI-guided biopsy has a high probability to be more cost-effective as compared with the classical prostate cancer screening pathway.

The role of modelling in the policy decision making process for cancer screening: example of prostate specific antigen screening.

Although randomised controlled trials are the preferred basis for policy decisions on cancer screening, it remains difficult to assess all downstream effects of screening, particularly when screening options other than those in the specific trial design are being considered. Simulation models of the natural history of disease can play a role in quantifying harms and benefits of cancer screening scenarios. Recently, the US Preventive Services Task Force issued a C-recommendation on screening for prostate cancer for men aged 55-69 years, implying at least moderate certainty that the benefit is small. However, modelling based on data from the European Randomized study of Screening for Prostate Cancer, which included quality-of-life estimates, showed that the ratio between benefits and harms is better, and likely to be reasonable, for men screened between the ages of 55 and 63 years (i.e. by using an earlier stopping age than applied in the trial setting). This commentary article considers the importance of simulation modelling in the decision-making process for (prostate) cancer screening. The paper also explores whether the recently published Cluster Randomized Trial of PSA Testing for Prostate Cancer, a trial of a single prostate specific antigen (PSA) testing intervention in the UK, changes the evidence for regular PSA testing for men aged 55-63 years by replicating the trial using a simulation model.

Breast cancer incidence trends in Norway and estimates of overdiagnosis.

Objective Fluctuations in the incidence of breast cancer in Norway in the last three decades are partly explained by the use of hormone replacement therapy and mammography screening, but overdiagnosis has also been suggested as a cause. We assessed the trends in breast cancer incidence and overdiagnosis in Norway. Methods We calibrated our microsimulation model to Norwegian Cancer Registration data. The model takes into account the use of mammography (both within and outside the Norwegian Breast Cancer Screening Programme) and of hormone replacement therapy. We obtained a proper fit of breast cancer incidence in recent years, when assuming an increase in the background risk for breast cancer, and estimated overdiagnosis. Results We estimated a 2% overdiagnosis rate as a fraction of all cancers diagnosed in women aged 50-100, and a 3% overdiagnosis rate as a fraction of all cancers diagnosed in women aged 50-70 (i.e. screening age). If all of the increased incidence would be the result of the detection of slow growing tumours, these estimates were 7% and 11%, respectively. Conclusion Besides mammography and hormone replacement therapy use, additional risk factors contributed to the sudden increase in breast cancer incidence in Norway. Overdiagnosis estimates due to screening were within the range of international plausible estimates.

The role of pre-invasive disease in overdiagnosis: A microsimulation study comparing mass screening for breast cancer and cervical cancer.

OBJECTIVE: Although early detection of cancer through screening can prevent cancer deaths, a drawback of screening is overdiagnosis. Overdiagnosis has been much debated in breast cancer screening, but less so in cervical cancer screening. We examined the impact of overdiagnosis by comparing two screening programmes in the Netherlands. METHODS: We estimated overdiagnosis rates by microsimulation for breast cancer screening and cervical cancer screening, using a cohort of women born in 1982 with lifelong follow-up. Overdiagnosis estimates were made analogous to two definitions formed by the UK 2012 breast screening review. Pre-invasive disease was included in both definitions. RESULTS: Screening prevented 921 cervical cancers (-55%) and 378 cervical cancer deaths (-59%), and 169 (-1.3%) breast cancer cases and 970 breast cancer deaths (-21%). The cervical cancer overdiagnosis rate was 74.8% (including pre-invasive disease). Breast cancer overdiagnosis was estimated at 2.5% (including pre-invasive disease). For women of all ages in breast cancer screening, an excess of 207 diagnoses/100,000 women was found, compared with an excess of 3999 diagnoses/100,000 women in cervical cancer screening. CONCLUSIONS: For breast cancer, the frequency of overdiagnosis in screening is relatively low, but consequences are evident. For cervical cancer, the frequency of overdiagnosis in screening is high, because of detection of pre-invasive disease, but the consequences per case are relatively small due to less invasive treatment. This illustrates that it is necessary to present overdiagnosis in relation to disease stage and consequences.