Breast Cancer Screening Using Clinical Breast Examination: A Cost-Effectiveness Analysis for South Africa

The World Health Organization emphasizes screening and early diagnosis to reduce advanced cancer incidence and mortality. In low-to-middle-income countries, breast cancer (BC) survival rates are low because of late detection. South Africa's policy recommends twice-yearly clinical breast examinations (CBEs) for asymptomatic women aged 40 to 69. We assessed the impact of scaling up CBE screening on mortality and cost-effectiveness.

Using trial data on downstaging, we compared the current baseline (5% coverage) with scenario 1 (25% coverage by year 5 [ie, 5% increase annually]) and scenario 2 (75% coverage by year 5, [ie, 17.5% increase annually]). A cohort model tracked women from screening to diagnosis, estimating downstaging's impact on BC cases over their lifetime. Costs from the healthcare payer's perspective are presented in 2022 US dollars.

Five-year screen detection rates were 2.39 and 2.08 per 1000 women screened for scenarios 1 and 2, respectively. Scenario 1 reduced BC mortality by 0.7% and scenario 2 by 2.3%. Compared with no screening, the current baseline screening program averts 1645 disability-adjusted life years (DALYs) at $20 341/DALY averted. Scenario 1 averted 3823 DALYs with economic efficiency improving to $17 776/DALY averted, whereas scenario 2 averted 12 165 DALYs at $19 552/DALY averted.

CBE scale-up effectively saves life years but is not cost-effective under the country's opportunity cost-derived threshold of $3015/DALY averted. However, decisions on the best screening policy are not solely based on cost-effectiveness. They involve careful consideration of budgetary constraints and competing healthcare priorities. Scale-up should consider system capacity, minimum care standards and cost-effective early detection strategies.