Stout Natasha K, Rosenberg Marjorie A, Trentham-Dietz Amy, Smith Maureen A, Robinson Stephen M, Fryback Dennis G
Center for Risk Analysis, Harvard School of Public Health, Boston, MA 02115, USA.
J Natl Cancer Inst. 2006 Jun 7;98(11):774-82. doi: 10.1093/jnci/djj210.
Many guidelines recommend screening mammography every 1-2 years for women older than 40 years; more than 70% of women now participate in routine screening. No studies have examined the societal impact of screening practices over the past decade in the United States on costs and quality-adjusted life-years (QALYs). We performed a retrospective cost-effectiveness analysis comparing actual and alternative screening mammography scenarios.
We used a discrete-event simulation model of breast cancer epidemiology to estimate the costs and the number of QALYs that were associated with observed screening mammography patterns in the United States from 1990 to 2000 for women aged 40 years or older. We also estimated costs and QALYS for no screening and for 64 alternative screening scenarios. Incremental cost-effectiveness ratios were computed. Sensitivity analyses were performed on key parameters.
Actual U.S. screening patterns from 1990 to 2000 accrued 947.5 million QALYs and cost $166 billion over the lifetimes of the screened women, resulting in a gain of 1.7 million QALYs for an additional cost of $62.5 billion compared with no screening. Among those polices that were not dominated--i.e., for which no alternative existed that produced more QALYs for lower costs--screening all women aged 40-80 years annually per some U.S. guidelines was the most expensive option, costing $58,000 per additional QALY gained compared with the next most costly alternative, screening all women aged 45-80 years annually. Many alternative screening scenarios generated more QALYs for less cost (with savings up to $6 billion) than actual screening patterns over the study period. Sensitivity analysis showed that conclusions about the cost-effectiveness of screening mammography policies were highly sensitive to small, short-term detrimental effects on quality of life from the screening test itself.
Choosing among the efficient policies to guide current screening recommendations requires consideration of costs to promote participation in screening and measurement of acute quality-of-life effects of mammography.
许多指南建议40岁以上女性每1 - 2年进行一次乳腺钼靶筛查；现在超过70%的女性参与常规筛查。在美国，过去十年中尚无研究探讨筛查实践对成本和质量调整生命年（QALY）的社会影响。我们进行了一项回顾性成本效益分析，比较了实际和替代的乳腺钼靶筛查方案。
我们使用乳腺癌流行病学的离散事件模拟模型，估计了1990年至2000年美国40岁及以上女性观察到的乳腺钼靶筛查模式相关的成本和QALY数量。我们还估计了不进行筛查和64种替代筛查方案的成本和QALY。计算了增量成本效益比。对关键参数进行了敏感性分析。
1990年至2000年美国的实际筛查模式在接受筛查女性的一生中累计产生了9.475亿QALY，成本为1660亿美元，与不进行筛查相比，额外成本625亿美元可使QALY增加170万。在那些未被其他方案占优的策略中——即不存在以更低成本产生更多QALY的替代方案——按照美国的一些指南每年对所有40 - 80岁女性进行筛查是最昂贵的选择，与第二昂贵的替代方案（每年对所有45 - 80岁女性进行筛查）相比，每增加一个获得的QALY成本为58000美元。在研究期间，许多替代筛查方案比实际筛查模式以更低成本产生了更多QALY（节省高达60亿美元）。敏感性分析表明，关于乳腺钼靶筛查政策成本效益的结论对筛查测试本身对生活质量的微小短期不利影响高度敏感。
在指导当前筛查建议的有效政策中进行选择时，需要考虑促进筛查参与的成本以及乳腺钼靶检查对急性生活质量影响的测量。
