The U.S. Preventive Services Task Force recommends screening mammography for women only through age 74 years. The American Cancer Society recommends screening mammography for women beyond age 74 years if they have a life expectancy of 10 or more years. This article attempts to resolve this discrepancy.
Abstract
Background:
The cost-effectiveness of screening mammography beyond age 75 years remains unclear.
Objective:
To estimate benefits, harms, and cost-effectiveness of extending mammography to age 80, 85, or 90 years according to comorbidity burden.
Design:
Markov microsimulation model.
Data Sources:
SEER (Surveillance, Epidemiology, and End Results) program and Breast Cancer Surveillance Consortium.
Target Population:
U.S. women aged 65 to 90 years in groups defined by Charlson comorbidity score (CCS).
Time Horizon:
Lifetime.
Perspective:
National health payer.
Intervention:
Screening mammography to age 75, 80, 85, or 90 years.
Outcome Measures:
Breast cancer death, survival, and costs.
Results of Base-Case Analysis:
Extending biennial mammography from age 75 to 80 years averted 1.7, 1.4, and 1.0 breast cancer deaths and increased days of life gained by 5.8, 4.2, and 2.7 days per 1000 women for comorbidity scores of 0, 1, and 2, respectively. Annual mammography beyond age 75 years was not cost-effective, but extending biennial mammography to age 80 years was ($54 000, $65 000, and $85 000 per quality-adjusted life-year [QALY] gained for women with CCSs of 0, 1, and ≥2, respectively). Overdiagnosis cases were double the number of deaths averted from breast cancer.
Results of Sensitivity Analysis:
Costs per QALY gained were sensitive to changes in invasive cancer incidence and shift of breast cancer stage with screening mammography.
Limitation:
No randomized controlled trials of screening mammography beyond age 75 years are available to provide model parameter inputs.
Conclusion:
Although annual mammography is not cost-effective, biennial screening mammography to age 80 years is; however, the absolute number of deaths averted is small, especially for women with comorbidities. Women considering screening beyond age 75 years should weigh the potential harms of overdiagnosis versus the potential benefit of averting death from breast cancer.
Primary Funding Source:
National Cancer Institute and National Institutes of Health.
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Author, Article, and Disclosure Information
John T. Schousboe,
Park Nicollet Clinic and HealthPartners Institute, HealthPartners, Bloomington, and Division of Health Policy and Management, University of Minnesota, Minneapolis, Minnesota (J.T.S.)
Departments of Surgery and Radiology, The University of Vermont, Burlington, Vermont (B.L.S.)
Kaiser Permanente Washington Health Research Institute, Seattle, Washington (L.A., E.S.O., K.J.W.)
Department of Population Health Sciences and Huntsman Cancer Institute, The University of Utah, Salt Lake City, Utah (T.O.)
Department of Oncology, School of Medicine, Georgetown University, Washington, DC, and Terasaki Institute for Biomedical Innovation, Los Angeles, California (S.A.)
Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (L.M.H.)
Cancer Control and Population Sciences Program and Department of Epidemiology, University of Florida, Gainesville, Florida (D.Z.)
Department of Public Health Sciences, University of California, Davis, California, and Kaiser Permanente Washington Health Research Institute, Seattle, Washington (D.L.M.)
Cancer Control and Population Sciences Program, Department of Epidemiology, and Institute on Aging, University of Florida, Gainesville, Florida (D.B.)
Departments of Medicine and Epidemiology and Biostatistics and Department of Veterans Affairs (VA) Division of General Internal Medicine, University of California, San Francisco, San Francisco, California (K.K.).
Disclaimer: All statements, findings, and conclusions in this report are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute, its board of governors, or its methodology committee, nor those of the National Cancer Institute or the National Institutes of Health.
Acknowledgment: The authors thank the participating women, facilities, and radiologists for the BCSC data they have provided (www.bcsc-research.org).
Grant Support: By National Cancer Institute grant R01 CA207361. Data collection was additionally supported by the BCSC with funding from the National Cancer Institute (grants P01 CA154292, U54CA163303, and R01CA149365), the Patient-Centered Outcomes Research Institute (grant PCS-1504-30370), and the Agency for Healthcare Research and Quality (grant R01 HS018366-01A1). Cancer data collection from BCSC was supported in part by several state public health departments and cancer registries (www.bcsc-research.org/about/work-acknowledgement).
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-8076.
Reproducible Research Statement: Study protocol and data set: Not available. Statistical code: We believe that the microsimulation model can be recreated from the information in the Supplement. Readers interested in recreating the model should contact Dr. Schousboe (e-mail, john.
Corresponding Author: John T. Schousboe, MD, PhD, 3800 Park Nicollet Boulevard, St. Louis Park, MN 55416; e-mail, john.
Author Contributions: Conception and design: J.T. Schousboe, B.L. Sprague, T. Onega, S. Advani, L.M. Henderson, D.L. Miglioretti, D. Braithwaite, K. Kerlikowske.
Analysis and interpretation of the data: J.T. Schousboe, B.L. Sprague, E.S. O’Meara, T. Onega, S. Advani, K.J. Wernli, D.L. Miglioretti, K. Kerlikowske.
Drafting of the article: J.T. Schousboe, E.S. O’Meara, S. Advani, K.J. Wernli, K. Kerlikowske.
Critical revision of the article for important intellectual content: J.T. Schousboe, B.L. Sprague, T. Onega, L.M. Henderson, K.J. Wernli, D. Zhang, D.L. Miglioretti, D. Braithwaite, K. Kerlikowske.
Final approval of the article: J.T. Schousboe, B.L. Sprague, L. Abraham, E.S. O’Meara, T. Onega, S. Advani, L.M. Henderson, K.J. Wernli, D. Zhang, D.L. Miglioretti, D. Braithwaite, K. Kerlikowske.
Provision of study materials or patients: T. Onega, L.M. Henderson, D.L. Miglioretti, K. Kerlikowske.
Statistical expertise: J.T. Schousboe, D.L. Miglioretti.
Obtaining of funding: B.L. Sprague, L.M. Henderson, D.L. Miglioretti, D. Braithwaite, K. Kerlikowske.
Administrative, technical, or logistic support: K.J. Wernli, K. Kerlikowske.
Collection and assembly of data: J.T. Schousboe, B.L. Sprague, L. Abraham, E.S. O’Meara, T. Onega, L.M. Henderson, K.J. Wernli, D.L. Miglioretti, K. Kerlikowske.
This article was published at Annals.org on 23 November 2021.
* Drs. Braithwaite and Kerlikowske are co–senior authors.
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