Journal of the National Cancer Institute Advance Access published online on September 9, 2008
JNCI Journal of the National Cancer Institute, doi:10.1093/jnci/djn292
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© The Author 2008. Published by Oxford University Press.
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Breast Cancer Screening Policies in Developing Countries: A Cost-effectiveness Analysis for India
Affiliations of authors: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands (QLO, GD, AdK, HJdK); Netherlands Institute for Health Sciences, Rotterdam, The Netherlands (QLO); National Institutes of Health, Division Cancer Control & Population Sciences, Health Services & Economics Branch, Bethesda, MD (MLB)
Correspondence to: Dr Harry J. de Koning, Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands (e-mail: h.dekoning{at}erasmusmc.nl).
Background: India, the largest developing country, has a steadily rising incidence of breast cancer. Estimates and comparisons of the cost-effectiveness of feasible breast cancer screening policies in developing countries and identification of the determinants of cost and efficacy are needed.
Methods: A Microsimulation Screening Analysis model of breast cancer was calibrated to available data on breast cancer incidence, stage distribution, and mortality in India. The model was used to estimate the costs of screening for breast cancer in India, its effects on mortality, and its cost-effectiveness (ie, costs of screening per life-year gained or life saved). Screening using clinical breast examination (CBE) or mammography among different age groups and at various frequencies was analyzed. Costs were expressed in international dollars (Int.$), the currency used by the World Health Organization, which has the same purchasing power in India as the US dollar has in the United States. To determine which factors influenced cost-effectiveness, sensitivity analyses were performed.
Results: The estimated mortality reduction was the greatest for programs targeting women between age 40 and 60 years. Using a 3% discount rate, a single CBE at age 50 had an estimated cost-effectiveness ratio of Int.$793 per life year gained and a breast cancer mortality reduction of 2%. The cost-effectiveness ratio increased to Int.$1135 per life year gained for every-5-year CBE (age 40–60 years) and to Int.$1341 for biennial CBE (age 40–60 years); the corresponding reductions in breast cancer mortality were 8.2% and 16.3%, respectively. CBE performed annually from ages 40 to 60 was predicted to be nearly as efficacious as biennial mammography screening for reducing breast cancer mortality while incurring only half the net costs. The main factors affecting cost-effectiveness were breast cancer incidence, stage distribution, and cost savings on prevented palliative care.
Conclusion: The estimated cost-effectiveness of CBE screening for breast cancer in India compares favorably with that of mammography in developed countries. However, in view of competing priorities and economic conditions, the introduction of screening in India represents a greater challenge than it has been in more developed countries.
| Context and Caveats Prior knowledge The incidence of breast cancer in India is rising, but estimates of costs and effectiveness of different screening strategies in this developing country are needed. Study design Life histories of breast cancer patients were modeled as a Markov process using the Dutch MISCAN (MIcrosimulation SCreening ANalysis) model. A lower cumulative incidence and delayed diagnosis based on Indian data was incorporated into the model. Estimates of costs for diagnosis and treatment relied on Dutch data for resource usage and World Health Organization estimates of unit costs for South Asia. Contribution Estimated mortality reduction was greatest for screening programs targeting women between the ages of 40 and 60. Clinical breast examination (CBE) performed annually from ages 40 to 60 was predicted to be nearly as efficacious as biennial mammography screening for reducing breast cancer deaths, but only half as costly. Implications Although the estimated cost-effectiveness of CBE screening for breast cancer in India compares favorably with that of mammography in developed countries, introduction of screening in India remains a considerable economic challenge. Limitations The study relied on a number of assumptions concerning the efficacy of CBE in reducing breast cancer mortality in India that have not been verified in randomized trials. From the Editors
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Manuscript received December 11, 2007; revised June 25, 2008; accepted July 18, 2008.
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