Originally published as JCO Early Release 10.1200/JCO.2004.05.009 on June 1 2004

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Benefits and Costs of Interventions to Improve Breast Cancer Outcomes in African American Women

From the Department of Oncology, Georgetown University Medical Center, and Cancer Control Program, Lombardi Cancer Center, Washington, DC; Department of Family Medicine, Albert Einstein School of Medicine, Bronx; City University of New York, New York; Health Policy Research Center at the Robert J. Milano Graduate School of Management and Urban Policy at the New School for Social Research, New York, NY; and the Department of Health Studies and University of Chicago Cancer Research Center, University of Chicago, Chicago, IL

Address reprint requests to Jeanne Mandelblatt, MD, MPH, Lombardi Cancer Center, 2233 Wisconsin Ave, Suite 317, Washington, DC 20007; e-mail: mandelbj{at}georgetown.edu

PURPOSE: Historically, African American women have experienced higher breast cancer mortality than white women, despite lower incidence. Our objective was to evaluate whether costs of increasing rates of screening or application of intensive treatment will be off-set by survival benefits for African American women.

METHODS: We use a stochastic simulation model of the natural history of breast cancer to evaluate the incremental societal costs and benefits of status quo versus targeted biennial screening or treatment improvements among African Americans 40 years of age and older. Main outcome measures were number of mammograms, stage, all-cause mortality, and discounted costs per life year saved (LYS).

RESULTS: At the current screening rate of 76%, there is little incremental benefit associated with further increasing screening, and the costs are high: $124,053 and $124,217 per LYS for lay health worker and patient reminder interventions, respectively, compared with the status quo. Using reminders would cost $51,537 per LYS if targeted to virtually unscreened women or $78,130 per LYS if targeted to women with a two-fold increase in baseline risk. If all patients received the most intensive treatment recommended, costs increase but deaths decrease, for a cost of $52,678 per LYS. Investments of up to $6,000 per breast cancer patient could be used to enhance treatment and still yield cost-effectiveness ratios of less than $75,000 per LYS.

CONCLUSION: Except in pockets of unscreened or high-risk women, further investments in interventions to increase screening are unlikely to be an efficient use of resources. Ensuring that African American women receive intensive treatment seems to be the most cost-effective approach to decreasing the disproportionate mortality experienced by this population.

Supported by grants K05 CA96940 (J.S.M.) and RO1 CA72908 (J.S.M., K.R.Y., C.B.S., P.M., and M.F.) and cooperative agreement No. UO1-CA88293A from the National Cancer Institute (J.S.M., K.R.Y.,W.L., C.B.S., J.C., Y.C., and J.D.), Bethesda, MD.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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