Cost-effectiveness analysis of breast cancer screening using mammography in Singapore: a modelling study

Background Limited research is available on the cost-effectiveness of breast cancer screening programs in Asian countries. We evaluated the cost-effectiveness of Singapore's national mammography screening program, implemented in 2002, recommending annual screening between ages 40-49 and biennial screening between ages 50-69, and alternative screening scenarios taking into account important country-specific factors. Methods We used national data from Singapore in the MIcrosimulation SCreening ANalysis-Fatal diameter (MISCAN-Fadia) model to simulate 302 screening scenarios for 10 million women born between 1910-1969. Screening scenarios varied by starting and ending age, screening interval and attendance. Outcome measures included: life-years gained (LYG), breast cancer deaths averted, false positives, overdiagnosis, Quality-Adjusted-Life-Years (QALYs), costs (in 2002 Singapore dollars; S$), and incremental cost-effectiveness ratios (ICERs). Costs and effects were calculated and discounted with 3% using a health-care provider's perspective. Results Singapore's current screening program at observed attendance levels required 54,158 mammograms per 100,000 women, yielded 1,054 LYG and averted 57 breast-cancer deaths. At attendance rates {greater than or equal to}50%, the current program was near the efficiency frontier. Most scenarios on the efficiency frontier started screening at age 40. The ICERs of the scenarios on the efficiency frontiers ranged between S$10,186-S$56,306/QALY, which is considered cost-effective at a willingness-to-pay threshold of S$70,000/QALY gained. Conclusion Singapore's current screening program lies near the efficiency frontier and starting screening at age 40 or 45 is cost-effective. Furthermore, enhancing screening attendance rates would increase benefits while maintaining cost-effectiveness. Impact Screening all women at age 40 or 45 is cost-efficient in Singapore and a policy change may be considered.