Comparing the cost-benefit of breast cancer screening programs in rural and urban areas across four economic zones in China: a Markov modeling analysis
Authors: Zhou Dachuang , Zhou Kejia , Shao Hanqiao , Wang Wenjuan , Li Jiaqi , Tang Wenxi 
Published: September 2023

Abstract
Background:The aim of this study was to evaluate the cost-benefit of a population-level breast cancer screening program in rural and urban areas across four economic zones in China.
Methods:A decision-analytic Markov model was employed to assess the costs and benefits of 6,720 breast cancer screening program scenarios, consisting of 140 starting and ending age combinations and 48 screening technology alternatives, from a societal perspective in rural and urban areas across four economic zones. A cohort of all participants aged 0 years old was followed through 100 one-year Markov cycles. Separate analyses were conducted for eight distinct settings. Relevant parameters, including incidence, transition probability, screening and treatment compliance, screening sensitivity and specificity, utility, and mortality, were primarily sourced from published research in China and partially from other countries. Screening costs were derived from the median medical cost price statistics within the four economic zones. The primary outcome was incremental net benefit (INB) using quality-adjusted life-years (QALYs). One-way deterministic and simulated probabilistic sensitivity analyses were performed to address uncertainty.
Results In the absence of universal screening, the total average expected costs for one individual were $1,568, $1,972, $1,729, $1,943, $2,408, $3,102, $0,675, and $1,156 in rural and urban western, central, eastern, and northeastern China, respectively. A total of 6,720 strategies were simulated in each setting. When the local per capita gross domestic product (GDP) was used as the threshold, 84.01%, 97.42%, 95.34%, 97.68%, 97.96%, 98.17%, 93.57%, and 97.80% of universal screening strategies in rural and urban environments in western, central, eastern, and northeastern China were cost-effective compared to no universal screening. Under the threshold of three times the local per capita GDP, the percentages were 97.92%, 98.43%, 98.41%, 98.37%, 98.44%, 98.37%, and 98.44%, respectively. Using three times local per capita GDP as the willingness-to-pay threshold, the most cost-effective strategy under all eight environmental settings involved using near-infrared optical mammography as the initial screening, mammography as the secondary screening, and cytological examination as the final screening. Screening was conducted annually between the ages of 30 and 70, with INBs of US$74.94 (-83.22 to 1902.73), 92.73 (-83.62 to 963.45), 115.22 (-75.17 to 1228.98), 130.35 (-160.79 to 613.70), 114.54 (-107.38 to 1075.70)， 151.91 (-110.81 to 1103.50), 89.47 (-82.89 to 1515.46), and 174.03 (-142.59 to 1945.11), respectively. Compared to no screening, implementing screening could prevent 82.36%, 79.04%, 81.39%, 78.47%, 80.99%, 77.57%, 81.16%, and 78.04% of advanced breast cancer cases, and 51.61%, 49.58%, 51.11%, 49.44%, 50.88%, 48.83%, 50.85%, and 49.12% of breast cancer deaths, respectively. Our results remained robust and insensitive to extensive sensitivity analyses.
Conclusion Employing near-infrared optical mammography for initial screening, mammography for re-screening, and cytological examination for final screening, our study found that annual universal screening for Chinese women aged 30-70 years old was likely to be cost-effective in all settings. When the willingness-to-pay threshold was low, increasing the screening starting age seemed to be a more suitable option. Drawing from our comprehensive cost-benefit analysis and detailed examination of regional differences, this study offered valuable insights and guidance for government and policy makers to optimize the universal breast cancer screening program.