Cost-effectiveness of organised versus opportunistic mammography breast cancer screening in low-resourced country.

objectivesTo assess the cost-effectiveness of expanding the current opportunistic screening strategy to an organised and feasible population-based breast cancer screening strategy from the healthcare system perspective in Jordan.

designA probabilistic, state-transition cohort decision-analytic model was developed to estimate the expected incremental life years (LYs), quality-adjusted life years (QALYs) and costs.

participantsThe model includes a hypothetical cohort of average-risk asymptomatic Jordanian women aged 40 years and above.

interventionsThe base case comparison was between organised mammography with a 50% attendance rate and opportunistic mammography for asymptomatic women aged 40-70 years and older over a lifetime horizon. Multiple organised mammogram screening strategies were assessed that varied in screening interval and start and end age (strategy 1: 40-60 biennial, strategy 2: 50-65 annual, strategy 3: 50-65 biennial, strategy 4: 40-70 biennial, strategy 5: 50-70 biennial and strategy 6: 40-49 annual).

settingThis model-based economic evaluation study was conducted to reflect the context of the Jordanian healthcare system. MEASUREMENT: We identified, measured and valued resources and outcomes to populate the model. Transition probabilities were estimated from the literature, the cancer registry or through calibration. The screening test's specificity and sensitivity were obtained from the literature. Costs and utility weights were extracted from national databases and literature. Both costs and outcomes were discounted using an annual discount rate of 3%. The model's uncertainty was tested using deterministic and probabilistic sensitivity analysis.

resultsOver a lifetime horizon, strategy 3 (50-65 biennial, 50% attendance rate) resulted in a mean discounted LYs of 22.077, a mean discounted QALYs of 16.993 and a mean discounted cost of US$994 compared with opportunistic screening, which resulted in a mean discounted LYs of 22.062, a mean discounted QALYs of 16.980 and a mean discounted cost of US$889. The incremental cost-utility ratio (ICUR) relative to opportunistic screening is US$6734 per QALY. Strategy 3 ranks first as the most cost-effective organised screening strategy for the Jordanian healthcare system, followed by strategy 4 with an ICUR of US$18 024 per QALY and strategy 6 with an ICUR of US$62 418 per QALY. The three strategies were presented on the cost-effectiveness frontier. The deterministic sensitivity analysis showed that the results were sensitive to the cost of the screening package and the annual discount rate.

conclusionAt a willingness-to-pay cost-effectiveness threshold of US$42000-56000 per QALY, strategy 3 (50-65 biennial, 50% attendance rate) and strategy 4 (40-70 biennial, 50% attendance rate) are likely to be cost-effective in Jordan. However, prior to implementation, the affordability of each strategy and the availability of required infrastructure must be carefully evaluated.