Clinical Benefits, Harms, and Cost-Effectiveness of Breast Cancer Screening for Survivors of Childhood Cancer Treated With Chest Radiation : A Comparative Modeling Study

Ann Intern Med. 2020 Sep 1;173(5):331-341. doi: 10.7326/M19-3481. Epub 2020 Jul 7.


Background: Surveillance with annual mammography and breast magnetic resonance imaging (MRI) is recommended for female survivors of childhood cancer treated with chest radiation, yet benefits, harms, and costs are uncertain.

Objective: To compare the benefits, harms, and cost-effectiveness of breast cancer screening strategies in childhood cancer survivors.

Design: Collaborative simulation modeling using 2 Cancer Intervention and Surveillance Modeling Network breast cancer models.

Data sources: Childhood Cancer Survivor Study and published data.

Target population: Women aged 20 years with a history of chest radiotherapy.

Time horizon: Lifetime.

Perspective: Payer.

Intervention: Annual MRI with or without mammography, starting at age 25, 30, or 35 years.

Outcome measures: Breast cancer deaths averted, false-positive screening results, benign biopsy results, and incremental cost-effectiveness ratios (ICERs).

Results of base-case analysis: Lifetime breast cancer mortality risk without screening was 10% to 11% across models. Compared with no screening, starting at age 25 years, annual mammography with MRI averted the most deaths (56% to 71%) and annual MRI (without mammography) averted 56% to 62%. Both strategies had the most screening tests, false-positive screening results, and benign biopsy results. For an ICER threshold of less than $100 000 per quality-adjusted life-year gained, screening beginning at age 30 years was preferred.

Results of sensitivity analysis: Assuming lower screening performance, the benefit of adding mammography to MRI increased in both models, although the conclusions about preferred starting age remained unchanged.

Limitation: Elevated breast cancer risk was based on survivors diagnosed with childhood cancer between 1970 and 1986.

Conclusion: Early initiation (at ages 25 to 30 years) of annual breast cancer screening with MRI, with or without mammography, might reduce breast cancer mortality by half or more in survivors of childhood cancer.

Primary funding source: American Cancer Society and National Institutes of Health.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Breast Neoplasms / diagnosis*
  • Breast Neoplasms / diagnostic imaging
  • Breast Neoplasms / economics
  • Breast Neoplasms / etiology
  • Cancer Survivors* / statistics & numerical data
  • Cost-Benefit Analysis
  • Early Detection of Cancer* / adverse effects
  • Early Detection of Cancer* / economics
  • Early Detection of Cancer* / methods
  • Female
  • Humans
  • Magnetic Resonance Imaging / adverse effects
  • Magnetic Resonance Imaging / economics
  • Mammography* / adverse effects
  • Mammography* / economics
  • Models, Statistical
  • Practice Guidelines as Topic
  • Radiography, Thoracic / adverse effects*
  • Young Adult