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Cancer Med. 2019 Dec;8(18):7846-7858. doi: 10.1002/cam4.2498. Epub 2019 Sep 30.

Systematic reviews as a "lens of evidence": Determinants of cost-effectiveness of breast cancer screening.

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Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
Health Economic and Decision Science (HEDS), School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK.
The section of Early Detection and Prevention, International Agency for Research on Cancer, Lyon, France.
Collaborative Research Group for Evidence-Based Public Health, Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology, BIPS/University of Bremen, Bremen, Germany.
Department of Clinical Pharmacy and Pharmacy Management, Nnamdi Azikiwe University, Awka, Nigeria.
Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, The Netherlands.
Institute for Public Health and Nursing Research-IPP, Health Sciences Bremen, University of Bremen, Bremen, Germany.
Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogotá, Colombia.
Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia.


Systematic reviews with economic components are important decision tools for stakeholders seeking to evaluate technologies, such as breast cancer screening (BCS) programs. This overview of systematic reviews explores the determinants of the cost-effectiveness of BCS and assesses the quality of secondary evidence. The search identified 30 systematic reviews that reported on the determinants of the cost-effectiveness of BCS, including the costs of breast cancer and BCS. While the quality of the reviews varied widely, only four out of 30 papers were considered to be of a high quality. We did not identify publication bias in the original evidence on the cost-effectiveness of mammography screening; however, we highlight a need for improved clarity in both reporting and data verification. The reviews consisted mainly of studies from high-income countries. Breast cancer costs varied widely among the studies. Factors leading to higher costs included: time (diagnosis and last months before death), later stage or metastases, recurrence of the disease, age below 64 years and type of follow-up (more intensive or more specialized). Overall, screening with mammography was considered cost-effective in the age range 50-69 years in Western European and Northern American countries but not for older or younger women. Its cost-effectiveness was questionable for low-income settings and Asia. Mammography screening was more cost-effective with biennial screening compared to annual screening and single reading using computer-aided detection vs double reading. No information on the cost-effectiveness of ultrasonography was found, and there is much uncertainty on the cost-effectiveness of CBE because of methodological limitations.


breast cancer screening; cost-effectiveness; costs; review

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