Masuku Sithabiso D, Mandrik Olena, Mdege Noreen D, Mishra Gauravi, Muwonge Richard, Meyer-Rath Gesine, Lince-Deroche Naomi, Brennan Alan
Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; SCHARR, Sheffield Centre for Health and Related Research, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, England, UK.
SCHARR, Sheffield Centre for Health and Related Research, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, England, UK.
Value Health Reg Issues. 2025 Sep;49:101127. doi: 10.1016/j.vhri.2025.101127. Epub 2025 May 27.
The World Health Organization emphasizes screening and early diagnosis to reduce advanced cancer incidence and mortality. In low-to-middle-income countries, breast cancer (BC) survival rates are low because of late detection. South Africa's policy recommends twice-yearly clinical breast examinations (CBEs) for asymptomatic women aged 40 to 69. We assessed the impact of scaling up CBE screening on mortality and cost-effectiveness.
Using trial data on downstaging, we compared the current baseline (5% coverage) with scenario 1 (25% coverage by year 5 [ie, 5% increase annually]) and scenario 2 (75% coverage by year 5, [ie, 17.5% increase annually]). A cohort model tracked women from screening to diagnosis, estimating downstaging's impact on BC cases over their lifetime. Costs from the healthcare payer's perspective are presented in 2022 US dollars.
Five-year screen detection rates were 2.39 and 2.08 per 1000 women screened for scenarios 1 and 2, respectively. Scenario 1 reduced BC mortality by 0.7% and scenario 2 by 2.3%. Compared with no screening, the current baseline screening program averts 1645 disability-adjusted life years (DALYs) at $20 341/DALY averted. Scenario 1 averted 3823 DALYs with economic efficiency improving to $17 776/DALY averted, whereas scenario 2 averted 12 165 DALYs at $19 552/DALY averted.
CBE scale-up effectively saves life years but is not cost-effective under the country's opportunity cost-derived threshold of $3015/DALY averted. However, decisions on the best screening policy are not solely based on cost-effectiveness. They involve careful consideration of budgetary constraints and competing healthcare priorities. Scale-up should consider system capacity, minimum care standards and cost-effective early detection strategies.
世界卫生组织强调筛查和早期诊断，以降低晚期癌症的发病率和死亡率。在中低收入国家，由于发现较晚，乳腺癌（BC）的生存率较低。南非的政策建议对40至69岁无症状女性进行每年两次的临床乳房检查（CBE）。我们评估了扩大CBE筛查对死亡率和成本效益的影响。
利用关于疾病降期的试验数据，我们将当前基线（覆盖率5%）与方案1（到第5年覆盖率达到25%[即每年增加5%]）和方案2（到第5年覆盖率达到75%[即每年增加17.5%]）进行了比较。一个队列模型追踪女性从筛查到诊断的过程，估计疾病降期对其一生中BC病例的影响。从医疗保健支付者角度计算的成本以2022年美元表示。
方案1和方案2每1000名接受筛查的女性的五年筛查检出率分别为2.39和2.08。方案1使BC死亡率降低了0.7%，方案2降低了2.3%。与不进行筛查相比，当前的基线筛查项目以每避免一个伤残调整生命年（DALY）花费20341美元的代价避免了1645个DALY。方案1避免了3823个DALY，经济效率提高到每避免一个DALY花费17776美元，而方案2以每避免一个DALY花费19552美元的代价避免了12165个DALY。
扩大CBE筛查能有效挽救生命年，但根据该国源自机会成本的每避免一个DALY 3015美元的阈值，其成本效益不佳。然而，关于最佳筛查政策的决策并非仅基于成本效益。它们需要仔细考虑预算限制和相互竞争的医疗保健优先事项。扩大筛查应考虑系统能力、最低护理标准和具有成本效益的早期检测策略。
