telemammography for breast cancer screening a cost effective approach in argentina CORD-Papers-2022-06-02 (Version 1)

Title: Telemammography for breast cancer screening: a cost-effective approach in Argentina
Abstract: OBJECTIVES: Argentina is a low and middle-income country (LMIC) with a highly fragmented healthcare system that conflicts with access to healthcare stated by the countrys Universal Health Coverage plan. A tele-mammography network could improve access to breast cancer screening decreasing its mortality. This research aims to conduct an economic evaluation of the implementation of a tele-mammography program to improve access to healthcare. METHODS: A cost-utility analysis was performed to explore the incremental benefit of annual tele-mammography screening for at-risk Argentinian women over 40 years old. A Markov model was developed to simulate annual mammography or tele-mammography screening in two hypothetical population-based cohorts of asymptomatic women. Parameter uncertainty was evaluated through deterministic and probabilistic sensitivity analysis. Model structure uncertainty was also explored to test the robustness of the results. RESULTS: It was estimated that 31 out of 100 new cases of breast cancer would be detected by mammography and 39/100 by tele-mammography. The model returned an incremental cost-effectiveness ratio (ICER) of 26 051/quality-adjusted life-year (QALY) which is lower than the WHO-recommended threshold of 26 288/QALY for Argentina. Deterministic sensitivity analysis showed the ICER is most sensitive to the uptake and sensitivity of the screening tests. Probabilistic sensitivity analysis showed tele-mammography is cost-effective in 59% of simulations. DISCUSSION: Tele-mammography should be considered for adoption as it could improve access to expertise in underserved areas where adherence to screening protocols is poor. Disaggregated data by province is needed for a better- informed policy decision. Telemedicine could also be beneficial in ensuring the continuity of care when health systems are under stress like in the current COVID-19 pandemic. CONCLUSION: There is a 59% chance that tele-mammography is cost-effective compared to mammography for at-risk Argentinian women over 40- years old and should be adopted to improve access to healthcare in underserved areas of the country.
Published: 2021-07-19
Journal: BMJ Health Care Inform
DOI: 10.1136/bmjhci-2021-100351
DOI_URL: http://doi.org/10.1136/bmjhci-2021-100351
Author Name: Malek Pascha Victoria Alba
Author link: https://covid19-data.nist.gov/pid/rest/local/author/malek_pascha_victoria_alba
Author Name: Sun Li
Author link: https://covid19-data.nist.gov/pid/rest/local/author/sun_li
Author Name: Gilardino Ramiro
Author link: https://covid19-data.nist.gov/pid/rest/local/author/gilardino_ramiro
Author Name: Legood Rosa
Author link: https://covid19-data.nist.gov/pid/rest/local/author/legood_rosa
sha: 207dccafada16e79fa2f94cad9c15e2591695535
license: cc-by-nc
license_url: https://creativecommons.org/licenses/by-nc/4.0/
source_x: Medline; PMC; WHO
source_x_url: https://www.medline.com/https://www.ncbi.nlm.nih.gov/pubmed/https://www.who.int/
pubmed_id: 34281995
pubmed_id_url: https://www.ncbi.nlm.nih.gov/pubmed/34281995
pmcid: PMC8290945
pmcid_url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8290945
url: https://doi.org/10.1136/bmjhci-2021-100351 https://www.ncbi.nlm.nih.gov/pubmed/34281995/
has_full_text: TRUE
Keywords Extracted from Text Content: £ COVID-19 Tele-mammography £26 ICER tele-mammography women breast cancer cancer £30 GDP breast lump National Cancer Institute ranks breast cancer Argentina Value'=number Argentine US$ PSA Women cost-efficiently lung women ICER breast cancer Patient £8.72/test Competing human £38 406 £21 482 breast tissue VAMP £32 683 lung cancer centre Bahia Blanca PAHO £26 288/ £6644-£29 National Cancer £46 752 WTP ICER±8 patients beta PPP COVID-19 £ £44 508 patient airway cancer ARS £13 702 Bolivia, National Bank £26 Life' × Córdoba LMICs DSA malignancies Breast cancer telemammography Colombia
Extracted Text Content in Record: First 5000 Characters:Objectives Argentina is a low and middle-income country (LMIC) with a highly fragmented healthcare system that conflicts with access to healthcare stated by the country's Universal Health Coverage plan. A tele-mammography network could improve access to breast cancer screening decreasing its mortality. This research aims to conduct an economic evaluation of the implementation of a telemammography program to improve access to healthcare. Methods A cost-utility analysis was performed to explore the incremental benefit of annual tele-mammography screening for at-risk Argentinian women over 40 years old. A Markov model was developed to simulate annual mammography or tele-mammography screening in two hypothetical population-based cohorts of asymptomatic women. Parameter uncertainty was evaluated through deterministic and probabilistic sensitivity analysis. Model structure uncertainty was also explored to test the robustness of the results. Results It was estimated that 31 out of 100 new cases of breast cancer would be detected by mammography and 39/100 by tele-mammography. The model returned an incremental cost-effectiveness ratio (ICER) of £26 051/quality-adjusted life-year (QALY) which is lower than the WHO-recommended threshold of £26 288/QALY for Argentina. Deterministic sensitivity analysis showed the ICER is most sensitive to the uptake and sensitivity of the screening tests. Probabilistic sensitivity analysis showed tele-mammography is cost-effective in 59% of simulations. Discussion Tele-mammography should be considered for adoption as it could improve access to expertise in underserved areas where adherence to screening protocols is poor. Disaggregated data by province is needed for a better-informed policy decision. Telemedicine could also be beneficial in ensuring the continuity of care when health systems are under stress like in the current COVID-19 pandemic. Conclusion There is a 59% chance that telemammography is cost-effective compared to mammography for at-risk Argentinian women over 40years old, and should be adopted to improve access to healthcare in underserved areas of the country. Breast cancer is the leading cause of death from cancer in women from all social strata. Seventy per cent of the global-reported deaths were in low and middle-income countries (LMIC). 1 Population screening for breast cancer is strongly recommended by most guidelines, as it is highly curable if detected at early stages. The main goal is to allow diagnosis in asymptomatic women. The Surveillance, Epidemiology, and End Results programme of the US National Cancer Institute showed a good correlation of the stage at diagnosis with the 5-year survival rates: 62.5% of women are diagnosed at stage I/II, accounting for a 5-year survival rate of 85.5%-98.8%, contrasting with those diagnosed at stage III/IV, where the 5-year survival rate falls up to 30%. 2 The Argentinian National Cancer Institute ranks breast cancer as the most common cancer in the country with 19 000 cases diagnosed yearly. It represents 17% of all malignancies with an incidence of 71 per 100 000 and 32% of cancer in women. 3 It is the leading cause of death from cancer in women, with an estimated mortality rate of 18.0 per 100 000. According to the Pan American Health Summary What is already known? ► Telemedicine has been shown to be cost-effective in improving access to health services in rural areas and for chronic conditions by improving monitoring of patients and adherence to treatments. What does this paper add? ► With telemedicine having a crucial role in the screening and monitoring of chronic conditions during the COVID-19 pandemic, this would be the first paper that shows telemedicine-specifically telemammography-is cost-effective for breast cancer screening, and can guarantee the continuity of care and managing the surge caused by health emergencies like the current COVID-19 pandemic. ► It also opens up the possibility to explore the costeffectiveness of telemammography in other national healthcare systems, particularly for other low and middle-income countries. Organization (PAHO), Argentina ranks the second region for breast cancer mortality. 3 Argentina is a low to middle-income country where universal healthcare is guaranteed by the government. However, considerable inequalities in accessibility exist among different regions in the country, which challenge the adoption of mammography or ultrasonography for breast cancer screening and make it unaffordable for public and private healthcare providers in remote geographies. Telemammography networks are an affordable and scalable way of improving treatment and prevention of breast cancer. They usually operate with a main centre and strategically located digital mammography facilities, particularly in remote or in-need areas. Women go to these facilities to have their mammography taken, then the images are sent to the main centre to be interpreted and sent back to the facility in less than 24 hou
Keywords Extracted from PMC Text: ICER±8 breast tissue £13 702 Middle-Income Countryand lung £8.72/test Bolivia, 's breast cancer £30 region.15 Argentina PPP mastologist.19 patients £ £6644–£29 National Cancer National Cancer Institute ranks breast cancer Colombia £21 482 bias.28 Breast cancer COVID-19 Women ICER US$ Argentina Córdoba V.16.38 LMICs breast lump human lung cancer £38 406 GDP PSA programme.24 literature.16 DSA £26 beta Value'=number £46 752 airway cancer.22 23 centre consequence.26 quadrants airway cancer used.18 £32 683 telemammography women.3 malignancies £44 508 women cancer Bahia Blanca acceptance.24 Life'
Extracted PMC Text Content in Record: First 5000 Characters:Breast cancer is the leading cause of death from cancer in women from all social strata. Seventy per cent of the global-reported deaths were in low and middle-income countries (LMIC).1 Population screening for breast cancer is strongly recommended by most guidelines, as it is highly curable if detected at early stages. The main goal is to allow diagnosis in asymptomatic women. The Surveillance, Epidemiology, and End Results programme of the US National Cancer Institute showed a good correlation of the stage at diagnosis with the 5-year survival rates: 62.5% of women are diagnosed at stage I/II, accounting for a 5-year survival rate of 85.5%–98.8%, contrasting with those diagnosed at stage III/IV, where the 5-year survival rate falls up to 30%.2 The Argentinian National Cancer Institute ranks breast cancer as the most common cancer in the country with 19 000 cases diagnosed yearly. It represents 17% of all malignancies with an incidence of 71 per 100 000 and 32% of cancer in women.3 It is the leading cause of death from cancer in women, with an estimated mortality rate of 18.0 per 100 000. According to the Pan American Health Organization (PAHO), Argentina ranks the second region for breast cancer mortality.3 Argentina is a low to middle-income country where universal healthcare is guaranteed by the government. However, considerable inequalities in accessibility exist among different regions in the country, which challenge the adoption of mammography or ultrasonography for breast cancer screening and make it unaffordable for public and private healthcare providers in remote geographies. Telemammography networks are an affordable and scalable way of improving treatment and prevention of breast cancer. They usually operate with a main centre and strategically located digital mammography facilities, particularly in remote or in-need areas. Women go to these facilities to have their mammography taken, then the images are sent to the main centre to be interpreted and sent back to the facility in less than 24 hours. This could reduce the access barriers to early diagnosis by, first, improving access to state-of-the-art technology like digital mammography; second, improving diagnostic accuracy by a remote interpretation by trained physicians; third, increasing the breast cancer awareness through involvement of government bodies, civil societies and the private sector; and creating a pathway for national and regional cancer control programmes. This research aims to conduct a cost-utility analysis of the implementation of a telemammography programme to provide a summary measure of efficiency that can later be used to compare interventions across different healthcare programmes.4 Argentinian guidelines recommend annual screening with mammography for all women between 40 and 74 years old.5 Yet, access to the test is limited in rural areas where the uptake is as low as 39%.6 In this study, the current strategy was compared with a telemammographic approach. Both screening methods use the same machines (direct digital mammography and 3D mammography for women with denser breast tissue) which met the technical standards of the European guidelines for quality assurance in breast cancer screening and diagnosis.7 The number of devices used was 1 for each group. Both tests have a high sensitivity to detect a subset of the population who should have confirmatory biopsy to determine the presence or absence of disease.8 A state-transition Markov model was developed on Microsoft Excel V.16.38 to inform a long-term decision model (figure 1). In this study, we simulated annual mammography or telemammography screening methods for breast cancer in two hypothetical population-based cohorts of 1000 asymptomatic Argentinian women over 40 years old who were assumed to be at risk of breast cancer but had not yet been diagnosed. Figure 1 illustrates the natural history of the disease used in this evaluation, and was adapted from a published study.9 In each cycle, women could either remain cancer free, die from all-cause death or progress into stage I. From here, women could either subsequently transition into stages II, III, IV and cancer-related death or go directly into more severe stages (eg, I to III or I to IV directly). From each stage, women could die from other causes or cancer-related causes. Stage I cases detected by either screening test were treated accordingly if confirmed. The false negatives or missed cases by both tests that later on developed the disease were assumed to debut as 'new cases' progressing from healthy directly to stage II, III or IV. The invasive breast cancer incidence standardised by age was combined from four different provinces in Argentina: Bahia Blanca, Córdoba, Mendoza and Tierra del Fuego.10–12 The stage distribution data with telemammography were provided directly by a private telemammography firm in Argentina to improve the comparability of the results. These data are not publicly available. Non-detec
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