Cost-Effectiveness of Breast Cancer Screening in Women on Dialysis

Background: Breast cancer screening is recommended for women 50 years and older in most developed countries. Women on dialysis therapy have a risk of acquiring breast cancer similar to that for other women, but a greater all-cause mortality rate because of mortality from other competing causes. It is uncertain whether routine screening is cost-effective in women on dialysis therapy. In this study, we determine the costs and health outcomes of annual mammographic breast cancer screening in women on dialysis therapy. Study Design: We performed a cost-effectiveness analysis. Sensitivity and scenario analyses were performed to assess uncertainties in the model's parameter estimates. Base Case: A cohort (n = 1,000) of women on dialysis therapy aged 50 to 69 years in Australia. Model, Perspective, and Time Frame: A deterministic Markov model was developed from the perspective of a health care payer. Patients were followed up over their life time. Intervention: We compared a cohort of women who underwent annual mammography with a cohort that did not. Outcomes: Life-years saved (LYS), costs, and incremental cost-effectiveness ratio (ICER). Results: Average costs for a program of annual screening for a woman on dialysis therapy were $4,805 over 30 years. Incremental costs of screening were $403, and benefits were 0.0037 LYS. Five breast cancer deaths occurred in the screened arm and 6 breast cancer deaths occurred in the unscreened arm, a difference of 1 breast cancer averted by screening, with an estimated ICER of $109,852/LYS. The absolute reduction in breast cancer mortality was 0.1%, with a net gain in life expectancy of 1.3 days. The ICER was strongly dependent on age, with the most favorable ICER approximately $100,000/LYS at age 45 years. Limitations: Costs and clinical data were obtained from the nonindigenous Australian population and may not be generalizable to African Americans on dialysis therapy and indigenous populations from other countries. Conclusion: Using the most optimistic assumptions, survival gains expected from screening for breast cancer in women on dialysis therapy are very small. Annual population breast cancer screening should not be recommended for all women on dialysis therapy, but should be an individual decision between the patient and health care provider. Am J Kidney Dis 52:916-929. (C) 2008 by the National Kidney Foundation, Inc.