Breast Cancer Screening Among Childhood Cancer Survivors Treated Without Chest Radiation: Clinical Benefits and Cost-Effectiveness

Jennifer M. Yeh, Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.Follow
Kathryn P. Lowry, Department of Radiology, University of Washington and Seattle Cancer Care Alliance, Seattle, WA, USA.
Clyde B. Schechter, Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
Lisa R. Diller, Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
Grace O'Brien, Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.
Oguzhan Alagoz, Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA.
Gregory T. Armstrong, Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.Follow
John M. Hampton, Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA.
Melissa M. Hudson, Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.
Wendy Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
Qi Liu, Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada.
Jeanne S. Mandelblatt, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA.
Diana L. Miglioretti, Department of Public Health Sciences, University of California Davis School of Medicine, Davis, CA, USA.
Chaya S. Moskowitz, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Paul C. Nathan, The Hospital for Sick Children, Toronto, Ontario, Canada.
Joseph P. Neglia, Department of Pediatrics, University of Minnesota Medical School.
Kevin C. Oeffinger, Department of Medicine, Duke School of Medicine and Duke Cancer Institute, Durham, NC, USA.
Amy Trentham-Dietz, Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA.
Natasha K. Stout, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.

Abstract

BACKGROUND: Early initiation of breast cancer screening is recommended for high-risk women, including survivors of childhood cancer treated with chest radiation. Recent studies suggest that female survivors of childhood leukemia or sarcoma treated without chest radiation are also at elevated early onset breast cancer risk. However, the potential clinical benefits and cost-effectiveness of early breast cancer screening among these women are uncertain. METHODS: Using data from the Childhood Cancer Survivor Study, we adapted 2 Cancer Intervention and Surveillance Modeling Network simulation models to reflect the elevated risks of breast cancer and competing mortality among leukemia and sarcoma survivors. Costs and utility weights were based on published studies and databases. Outcomes included breast cancer deaths averted, false-positive screening results, benign biopsies, and incremental cost-effectiveness ratios. RESULTS: In the absence of screening, the lifetime risk of dying from breast cancer among survivors was 6.8% to 7.0% across models. Early initiation of annual mammography with breast magnetic resonance imaging screening between ages 25 and 40 years would avert 52.6% to 64.3% of breast cancer deaths. When costs and quality-of-life impacts were considered, screening starting at age 40 years was the only strategy with an incremental cost-effectiveness ratio below the $100 000 per quality-adjusted life-year (QALY) gained cost-effectiveness threshold ($27 680 to $44 380 per QALY gained across models). CONCLUSIONS: Among survivors of childhood leukemia or sarcoma, early initiation of breast cancer screening at age 40 years may reduce breast cancer deaths by half and is cost-effective. These findings could help inform screening guidelines for survivors treated without chest radiation.

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Journal of the National Cancer Institute

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