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The Clinical Effectiveness and Cost-Effectiveness of Different Surveillance Mammography Regimens After the Treatment for Primary Breast Cancer: Systematic Reviews, Registry Database Analyses and Economic Evaluation

Health Technology Assessment, No. 15.34

C Robertson, SK Arcot Ragupathy, C Boachie, JM Dixon, C Fraser, R Hernández, S Heys, W Jack, GR Kerr, G Lawrence, G MacLennan, A Maxwell, J McGregor, G Mowatt, S Pinder, L Ternent, RE Thomas, L Vale, R Wilson, S Zhu, and FJ Gilbert.

Author Information

C Robertson,1,* SK Arcot Ragupathy,2 C Boachie,1 JM Dixon,3 C Fraser,1 R Hernández,1,4 S Heys,5 W Jack,3 GR Kerr,6 G Lawrence,7 G MacLennan,1 A Maxwell,8 J McGregor,9 G Mowatt,1 S Pinder,10 L Ternent,1,3 RE Thomas,1 L Vale,1,3 R Wilson,11 S Zhu,1 and FJ Gilbert12.

1 Health Services Research Unit, University of Aberdeen, Aberdeen, UK
2 Radiology Department, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
3 Edinburgh Breast Unit, Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
4 Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
5 Division of Applied Medicine, School of Medicine and Dentistry, University of Aberdeen, and Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
6 Department of Clinical Oncology, Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
7 West Midlands Cancer Intelligence Unit, Birmingham Women's NHS Foundation Trust, Birmingham, UK
8 Breast Unit, Royal Bolton Hospital, Bolton, UK
9 Breast Cancer Care, London, UK
10 Research Oncology, Kings College, London, UK
11 Department of Clinical Radiology, The Royal Marsden, Sutton, UK
12 Aberdeen Biomedical Imaging Centre, University of Aberdeen, and Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
* Corresponding author
Southampton (UK): NIHR Journals Library; 2011 Sep.
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Abstract

Background:

Following primary breast cancer treatment, the early detection of ipsilateral breast tumour recurrence (IBTR) or ipsilateral secondary cancer in the treated breast and detection of new primary cancers in the contralateral breast is beneficial for survival. Surveillance mammography is used to detect these cancers, but the optimal frequency of surveillance and the length of follow-up are unclear.

Objectives:

To identify feasible management strategies for surveillance and follow-up of women after treatment for primary breast cancer in a UK setting, and to determine the effectiveness and cost-effectiveness of differing regimens.

Methods:

A survey of UK breast surgeons and radiologists to identify current surveillance mammography regimens and inform feasible alternatives; two discrete systematic reviews of evidence published from 1990 to mid 2009 to determine (i) the clinical effectiveness and cost-effectiveness of differing surveillance mammography regimens for patient health outcomes and (ii) the test performance of surveillance mammography in the detection of IBTR and metachronous contralateral breast cancer (MCBC); statistical analysis of individual patient data (West Midlands Cancer Intelligence Unit Breast Cancer Registry and Edinburgh data sets); and economic modelling using the systematic reviews results, existing data sets, and focused searches for specific data analysis to determine the effectiveness and cost–utility of differing surveillance regimens.

Results:

The majority of survey respondents initiate surveillance mammography 12 months after breast-conserving surgery (BCS) (87%) or mastectomy (79%). Annual surveillance mammography was most commonly reported for women after BCS or after mastectomy (72% and 53%, respectively). Most (74%) discharge women from surveillance mammography, most frequently 10 years after surgery. The majority (82%) discharge from clinical follow-up, most frequently at 5 years. Combining initiation, frequency and duration of surveillance mammography resulted in 54 differing surveillance regimens for women after BCS and 56 for women following mastectomy. The eight studies included in the clinical effectiveness systematic review suggest surveillance mammography offers a survival benefit compared with a surveillance regimen that does not include surveillance mammography. Nine studies were included in the test performance systematic review. For routine IBTR detection, surveillance mammography sensitivity ranged from 64% to 67% and specificity ranged from 85% to 97%. For magnetic resonance imaging (MRI), sensitivity ranged from 86% to 100% and specificity was 93%. For non-routine IBTR detection, sensitivity and specificity for surveillance mammography ranged from 50% to 83% and from 57% to 75%, respectively, and for MRI from 93% to 100% and from 88% to 96%, respectively. For routine MCBC detection, one study reported sensitivity of 67% and specificity of 50% for both surveillance mammography and MRI, although this was a highly select population. Data set analysis showed that IBTR has an adverse effect on survival. Furthermore, women experiencing a second tumour measuring > 20 mm in diameter were at a significantly greater risk of death than those with no recurrence or those whose tumour was < 10 mm in diameter. In the base-case analysis, the strategy with the highest net benefit, and most likely to be considered cost-effective, was surveillance mammography alone, provided every 12 months at a societal willingness to pay for a quality-adjusted life-year of either £20,000 or £30,000. The incremental cost-effectiveness ratio for surveillance mammography alone every 12 months compared with no surveillance was £4727.

Limitations:

Few studies met the review inclusion criteria and none of the studies was a randomised controlled trial. The limited and variable nature of the data available precluded any quantitative analysis. There was no useable evidence contained in the Breast Cancer Registry database to assess the effectiveness of surveillance mammography directly. The results of the economic model should be considered exploratory and interpreted with caution given the paucity of data available to inform the economic model.

Conclusions:

Surveillance is likely to improve survival and patients should gain maximum benefit through optimal use of resources, with those women with a greater likelihood of developing IBTR or MCBC being offered more comprehensive and more frequent surveillance. Further evidence is required to make a robust and informed judgement on the effectiveness of surveillance mammography and follow-up. The utility of national data sets could be improved and there is a need for high-quality, direct head-to-head studies comparing the diagnostic accuracy of tests used in the surveillance population.

Funding:

The National Institute for Health Research Health Technology Assessment programme.

Contents

Suggested citation:

Robertson C, Arcot Ragupathy SK, Boachie C, Dixon JM, Fraser C, Hernández RS, et al. The clinical effectiveness and cost-effectiveness of different surveillance mammography regimens after the treatment for primary breast cancer: systematic reviews, registry database analyses and economic evaluation. Health Technol Assess 2011;15(34).

Declared competing interests of authors: none

The research reported in this issue of the journal was commissioned by the HTA programme as project number 07/47/01. The contractual start date was in June 2008. The draft report began editorial review in February 2010 and was accepted for publication in September 2010. As the funder, by devising a commissioning brief, the HTA programme specified the research question and study design. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors' report and would like to thank the referees for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.

The views expressed in this publication are those of the authors and not necessarily those of the HTA programme or the Department of Health.

© 2011, Crown Copyright.

Included under terms of UK Non-commercial Government License.

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