Age Limits of Breast Cancer Screening with Mammography-A Decision-Analytic Benefit-Harm Evaluation to Inform...

Background/Objectives: To inform policy making for the German breast cancer (BC) screening program, we systematically evaluated the long-term benefits and harms of extended age limits compared to the current standard of biennial mammography at ages 50-69 years using a decision-analytic approach. Methods: We developed and applied a Markov state-transition model for mammography screening in Germany to systematically assess the benefit-harm trade-offs of various screening strategies varying in age at start and end of screening as well as in screening frequency. The model was populated with international data for sensitivity and specificity of mammography along with German epidemiological, clinical and age-specific quality-of-life data. In deterministic analyses, the following outcomes were projected: detected ductal carcinoma in situ (DCIS) and invasive BC, BC-related deaths, life years (LY), and quality-adjusted life years (QALY), number of positive, false-positive, and total mammograms, overdiagnosis, and the incremental harm-benefit ratio (IHBR). Results: In the base-case analysis, mammography at ages 45-79 (annual, age 45-49; biennial, 50-79) achieved the highest gain in LY (10.0 life years gained [LYG] per 100 women) compared with current screening. Biennial mammography at ages 45-74 resulted in the highest benefits considering both life expectancy and quality of life (3.5 QALYs gained/100 women). Compared to current biennial mammography screening at ages 50-69, lowering the start age from 50 to 45 years resulted in an IHBR of 47 additional mammograms/LYG. Compared to biennial mammography at ages 45-69, biennial mammography at age 45-74 results in 96 additional mammograms/LYG. Further extended screening results in substantially less favorable IHBRs. Conclusions: Based on our results, extending biennial mammography screening to women aged 45 to 74 years may prevent additional BC deaths and increase remaining life expectancy at an acceptable benefit-harm ratio, and improve quality-adjusted life expectancy.