Cost-Effectiveness of Magnetic Resonance Imaging Screening for Women With Extremely Dense Breast Tissue.
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ABSTRACT: Background
Extremely dense breast tissue is associated with increased breast cancer risk and limited sensitivity of mammography. The DENSE trial showed that additional magnetic resonance imaging (MRI) screening in women with extremely dense breasts resulted in a substantial reduction in interval cancers. The cost-effectiveness of MRI screening for these women is unknown.Methods
We used the MISCAN-breast microsimulation model to simulate several screening protocols containing mammography and/or MRI to estimate long-term effects and costs. The model was calibrated using results of the DENSE trial and adjusted to incorporate decreases in breast density with increasing age. Screening strategies varied in the number of MRIs and mammograms offered to women ages 50-75 years. Outcomes were numbers of breast cancers, life-years, quality-adjusted life-years (QALYs), breast cancer deaths, and overdiagnosis. Incremental cost-effectiveness ratios (ICERs) were calculated (3% discounting), with a willingness-to-pay threshold of €22 000.Results
Calibration resulted in a conservative fit of the model regarding MRI detection. Both strategies of the DENSE trial were dominated (biennial mammography; biennial mammography plus MRI). MRI alone every 4 years was cost-effective with €15 620 per QALY. Screening every 3 years with MRI alone resulted in an incremental cost-effectiveness ratio of €37 181 per QALY. All strategies with mammography and/or a 2-year interval were dominated because other strategies resulted in more additional QALYs per additional euro. Alternating mammography and MRI every 2 years was close to the efficiency frontier.Conclusions
MRI screening is cost-effective for women with extremely dense breasts, when applied at a 4-year interval. For a willingness to pay more than €22 000 per QALY gained, MRI at a 3-year interval is cost-effective as well.
SUBMITTER: Geuzinge HA
PROVIDER: S-EPMC8562952 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Background and Purpose- The VERiTAS (Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke) study demonstrated posterior circulation distal flow status, determined by quantitative magnetic resonance angiography, is a robust predictor of vertebrobasilar stroke risk in patients with symptomatic atherosclerotic vertebrobasilar disease. Flow-compromised high-risk patients may benefit from flow-restoring endovascular procedures, such as submaximal angioplasty. In this study, we examine the cost-effectiveness of quantitative magnetic resonance angiography screening to identify patients who may benefit from submaximal angioplasty to restore vertebrobasilar flow. Methods- A Markov model was created comparing a no screening strategy with standard medical management alone and a screening strategy involving quantitative magnetic resonance angiography imaging and submaximal angioplasty for treatable patients with low vertebrobasilar flow for a 30-year time horizon. Outcomes included quality-adjusted life years (QALY) and lifetime costs. Rates of stroke and death were obtained from VERiTAS data, and disability rates and costs were derived from VERiTAS and the literature. A sensitivity analysis was performed with periprocedural stroke rate from angioplasty the primary variable of interest. Results- At a 6% periprocedural stroke risk, the screening strategy saved an average of 0.364 QALYs per patient and a lifetime cost savings of $7312 versus the no screening strategy. Among patients with low flow suitable for intervention, the benefit was substantially higher, averaging 1.485 QALYs saved and lifetime cost savings of $21?294. Across the entire cohort, QALY savings were observed at the end of the first year and economic savings at year 6. The benefit of screening declined at higher periprocedural risk. Conclusions- Quantitative magnetic resonance angiography screening and submaximal angioplasty with 6% periprocedural risk in suitable patients are cost effective both in terms of QALY and lifetime costs for patients with symptomatic vertebrobasilar occlusive disease. With potential health and economic savings, a clinical trial examining the periprocedural risk of submaximal angioplasty is warranted. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT00590980.
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Project description:IntroductionMagnetic resonance imaging (MRI) has shown the potential to improve the screening effectiveness among women with dense breasts. The introduction of fast abbreviated protocols (AP) makes MRI more feasible to be used in a general population. We aimed to investigate the cost-effectiveness of AP-MRI in women with dense breasts (heterogeneously/extremely dense) in a population-based screening program.MethodsA previously validated model (SiMRiSc) was applied, with parameters updated for women with dense breasts. Breast density was assumed to decrease with increased age. The base scenarios included six biennial AP-MRI strategies, with biennial mammography from age 50-74 as reference. Fourteen alternative scenarios were performed by varying screening interval (triennial and quadrennial) and by applying a combined strategy of mammography and AP-MRI. A 3% discount rate for both costs and life years gained (LYG) was applied. Model robustness was evaluated using univariate and probabilistic sensitivity analyses.ResultsThe six biennial AP-MRI strategies ranged from 132 to 562 LYG per 10,000 women, where more frequent application of AP-MRI was related to higher LYG. The optimal strategy was biennial AP-MRI screening from age 50-65 for only women with extremely dense breasts, producing an incremental cost-effectiveness ratio of € 18,201/LYG. At a threshold of € 20,000/LYG, the probability that the optimal strategy was cost-effective was 79%.ConclusionPopulation-based biennial breast cancer screening with AP-MRI from age 50-65 for women with extremely dense breasts might be a cost-effective alternative to mammography, but is not an option for women with heterogeneously dense breasts.
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Project description:ImportanceIf magnetic resonance imaging (MRI) mitigates overdiagnosis of prostate cancer while improving the detection of clinically significant cases, including MRI in a screening program for prostate cancer could be considered.ObjectiveTo evaluate the benefit-harm profiles and cost-effectiveness associated with MRI before biopsy compared with biopsy-first screening for prostate cancer using age-based and risk-stratified screening strategies.Design, setting, and participantsThis decision analytical model used a life-table approach and was conducted between December 2019 and July 2020. A hypothetical cohort of 4.48 million men in England aged 55 to 69 years were analyzed and followed-up to 90 years of age.ExposuresNo screening, age-based screening, and risk-stratified screening in the hypothetical cohort. Age-based screening consisted of screening every 4 years with prostate-specific antigen between the ages of 55 and 69 years. Risk-stratified screening used age and polygenic risk profiles.Main outcomes and measuresThe benefit-harm profile (deaths from prostate cancer, quality-adjusted life-years, overdiagnosis, and biopsies) and cost-effectiveness (net monetary benefit, from a health care system perspective) were analyzed. Both age-based and risk-stratified screening were evaluated using a biopsy-first and an MRI-first diagnostic pathway. Results were derived from probabilistic analyses and were discounted at 3.5% per annum.ResultsThe hypothetical cohort included 4.48 million men in England, ranging in age from 55 to 69 years (median, 62 years). Compared with biopsy-first age-based screening, MRI-first age-based screening was associated with 0.9% (1368; 95% uncertainty interval [UI], 1370-1409) fewer deaths from prostate cancer, 14.9% (12 370; 95% UI, 11 100-13 670) fewer overdiagnoses, and 33.8% (650 500; 95% UI, 463 200-907 000) fewer biopsies. At 10-year absolute risk thresholds of 2% and 10%, MRI-first risk-stratified screening was associated with between 10.4% (7335; 95% UI, 6630-8098) and 72.6% (51 250; 95% UI, 46 070-56 890) fewer overdiagnosed cancers, respectively, and between 21.7% fewer MRIs (412 100; 95% UI, 411 400-412 900) and 53.5% fewer biopsies (1 016 000; 95% UI, 1 010 000-1 022 000), respectively, compared with MRI-first age-based screening. The most cost-effective strategies at willingness-to-pay thresholds of £20 000 (US $26 000) and £30 000 (US $39 000) per quality-adjusted life-year gained were MRI-first risk-stratified screening at 10-year absolute risk thresholds of 8.5% and 7.5%, respectively.Conclusions and relevanceIn this decision analytical model of a hypothetical cohort, an MRI-first diagnostic pathway was associated with an improvement in the benefit-harm profile and cost-effectiveness of screening for prostate cancer compared with biopsy-first screening. These improvements were greater when using risk-stratified screening based on age and polygenic risk profile and may warrant prospective evaluation.
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Project description:BackgroundThe introduction of multiparametric magnetic resonance imaging (mpMRI) and MRI-guided biopsy has improved the diagnosis of prostate cancer. However, it remains uncertain whether it is cost-effective, especially in a population-based screening strategy.MethodsWe used a micro-simulation model to assess the cost-effectiveness of an MRI-based prostate cancer screening in comparison to the classical prostate-specific antigen (PSA) screening, at a population level. The test sensitivity parameters for the mpMRI and MRI-guided biopsy, grade misclassification rates, utility estimates, and the unit costs of different interventions were obtained from literature. We assumed the same screening attendance rate and biopsy compliance rate for both strategies. A probabilistic sensitivity analysis, consisting of 1000 model runs, was performed to estimate a mean incremental cost-effectiveness ratio (ICER) and assess uncertainty. A €20,000 willingness-to-pay (WTP) threshold per quality-adjusted life year (QALY) gained, and a discounting rate of 3.5% was considered in the analysis.ResultsThe MRI-based screening improved the life-years (LY) and QALYs gained by 3.5 and 3, respectively, in comparison to the classical screening pathway. Based on the probabilistic sensitivity analyses, the MRI screening pathway leads to total discounted mean incremental costs of €15,413 (95% confidence interval (CI) of €14,556-€16,272) compared to the classical screening pathway. The corresponding discounted mean incremental QALYs gained was 1.36 (95% CI of 1.31-1.40), resulting in a mean ICER of €11,355 per QALY gained. At a WTP threshold of €20,000, the MRI screening pathway has about 84% chance to be more cost-effective than the classical screening pathway.ConclusionsFor triennial screening from age 55-64, incorporation of mpMRI as a reflex test after a positive PSA test result with a subsequent MRI-guided biopsy has a high probability to be more cost-effective as compared with the classical prostate cancer screening pathway.
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Project description:A quantitative estimate of cerebral blood oxygen saturation is of critical importance in the investigation of cerebrovascular disease. While positron emission tomography can map in vivo the oxygen level in blood, it has limited availability and requires ionizing radiation. Magnetic resonance imaging (MRI) offers an alternative through the blood oxygen level-dependent contrast. Here, we describe an in vivo and non-invasive approach to map brain tissue oxygen saturation (StO2) with high spatial resolution. StO2 obtained with MRI correlated well with results from blood gas analyses for various oxygen and hematocrit challenges. In a stroke model, the hypoxic areas delineated in vivo by MRI spatially matched those observed ex vivo by pimonidazole staining. In a model of diffuse traumatic brain injury, MRI was able to detect even a reduction in StO2 that was too small to be detected by histology. In a F98 glioma model, MRI was able to map oxygenation heterogeneity. Thus, the MRI technique may improve our understanding of the pathophysiology of several brain diseases involving impaired oxygenation.
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Project description:ObjectiveIntegrating cardiac-tissue patches into the beating heart and evaluating the long-term effects of such integration on cardiac contractility are two challenges in an emerging field of regenerative medicine. This pilot study presents tools for the imaging of contracting multicellular cardiac tissue constructs (MTCs) in vitro and demonstrates the feasibility of tracking the early development of strand geometry and contractions in ultrathin strands and layers of cardiac tissue using CINE MRI.ApproachCultured, ultrathin (~50-100-micron) MTCs of rat neonatal cardiomyocytes were plated in rectangular cell chambers (4.5 × 2.0 cm) with and without ultrathin, carbon EP electrodes embedded in the floor of the cell chamber. Two-dimensional, steady-state free precession (SSFP) CINE MRI, cell microscopy, and tissue photography were performed on Days 5-9 of cell development. Potential confounders and MRI artifacts were evaluated using non-contracting cardiac tissues and cell-free chambers filled with the cell-culture medium.Main resultsSynchronized contractions formed by Day 7; individual contracting tissue strands became identifiable by Day 9. The global patterns and details of the strand geometry and movement patterns in the SSFP images were in excellent agreement with microscopic and photographic images. No synchronized movement was identifiable by either microscopy or CINE MRI in the non-contracting MTCs or the cell-free medium. The EP recordings revealed well-defined depolarization and repolarization waveforms; the imaging artifacts generated by the carbon electrodes were small.SignificanceThis pilot study demonstrates the feasibility of imaging cardiac-strand patterns and contractile activity in ultrathin, two-dimensional cardiac tissue in commonly used clinical scanners.
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