Economic evaluation of supplemental breast cancer screening modalities to mammography or digital breast tomosynthesis in women with heterogeneously and extremely dense breasts and average or intermediate breast cancer risk in US healthcare.

OBJECTIVE: To evaluate the cost effectiveness of supplemental breast imaging modalities for women with heterogeneously and extremely dense breasts and average or intermediate risk of breast cancer (BC) in the USA, and analyze capacity requirements for supplemental magnetic resonance imaging (MRI) and contrast-enhanced mammography (CEM).

METHODS: Clinical and economic outcomes for supplemental imaging modalities including full- and abbreviated-protocol MRI (Fp-MRI, Ab-MRI), CEM, and ultrasound (U/S) as add-on to x-ray mammography (XM) or digital breast tomosynthesis (DBT), were compared to XM or DBT alone, in a decision tree linked to a Markov chain validated by comparison with a microsimulation analysis. A Delphi panel supplemented model input parameters from the literature. A capacity model evaluated the number of additional daily scans and scanners required for Fp-MRI and CEM.

RESULTS: Compared to XM or DBT alone, all supplemental imaging protocols were cost effective. Both Fp- and Ab-MRI, and to a lesser extent CEM and U/S, yielded superior clinical outcomes to XM or DBT. Compared to XM alone, U/S and Ab-MRI had the lowest incremental cost-effectiveness ratios (ICER). For U/S, the ICER was $23,394 for the average-risk population and $13,241 for the intermediate-risk population. For CEM, the ICER was $38,423 and $23,772, respectively. For the extremely dense subpopulation with intermediate risk, supplemental screening requirements could be accommodated by conducting one Fp-MRI scan per day per existing general scanner.

CONCLUSIONS: While ultrasound had the lowest ICER, MRI and CEM demonstrated the best clinical outcomes, compared to XM or DBT alone for women with dense breasts and intermediate and high risk. Existing MRI scanner capacity has the potential to meet most of the supplemental screening needs of this population.