Dataset Information

Should Age-Dependent Absolute Risk Thresholds Be Used for Risk Stratification in Risk-Stratified Breast Cancer Screening?

ABSTRACT: In risk-stratified cancer screening, multiple risk factors are incorporated into the risk assessment. An individual's estimated absolute cancer risk is linked to risk categories with tailored screening recommendations for each risk category. Absolute risk, expressed as either remaining lifetime risk or shorter-term (five- or ten-year) risk, is estimated from the age at assessment. These risk estimates vary by age; however, some clinical guidelines (e.g., enhanced breast cancer surveillance guidelines) and ongoing personalised breast screening trials, stratify women based on absolute risk thresholds that do not vary by age. We examine an alternative approach in which the risk thresholds used for risk stratification vary by age and consider the implications of using age-independent risk thresholds on risk stratification. We demonstrate that using an age-independent remaining lifetime risk threshold approach could identify high-risk younger women but would miss high-risk older women, whereas an age-independent 5-year or 10-year absolute risk threshold could miss high-risk younger women and classify lower-risk older women as high risk. With risk misclassification, women with an equivalent risk level would be offered a different screening plan. To mitigate these problems, age-dependent absolute risk thresholds should be used to inform risk stratification.

SUBMITTER: Pashayan N

PROVIDER: S-EPMC8469877 | biostudies-literature | 2021 Sep

REPOSITORIES: biostudies-literature

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Should Age-Dependent Absolute Risk Thresholds Be Used for Risk Stratification in Risk-Stratified Breast Cancer Screening?

Pashayan Nora N Antoniou Antonis C AC Lee Andrew A Wolfson Michael M Chiquette Jocelyne J Eloy Laurence L Eisen Andrea A Stockley Tracy L TL Nabi Hermann H Brooks Jennifer D JD Dorval Michel M Easton Douglas F DF Knoppers Bartha Maria BM Chiarelli Anna M AM Simard Jacques J

Journal of personalized medicine 20210915 9

In risk-stratified cancer screening, multiple risk factors are incorporated into the risk assessment. An individual's estimated absolute cancer risk is linked to risk categories with tailored screening recommendations for each risk category. Absolute risk, expressed as either remaining lifetime risk or shorter-term (five- or ten-year) risk, is estimated from the age at assessment. These risk estimates vary by age; however, some clinical guidelines (e.g., enhanced breast cancer surveillance guide ...[more]

PMID: 34575693

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Project description:ImportancePrevious research has shown good discrimination of short-term risk using an artificial intelligence (AI) risk prediction model (Mirai). However, no studies have been undertaken to evaluate whether this might translate into economic gains.ObjectiveTo assess the cost-effectiveness of incorporating risk-stratified screening using a breast cancer AI model into the United Kingdom (UK) National Breast Cancer Screening Program.Design, setting, and participantsThis study, conducted from January 1, 2023, to January 31, 2024, involved the development of a decision analytical model to estimate health-related quality of life, cancer survival rates, and costs over the lifetime of the female population eligible for screening. The analysis took a UK payer perspective, and the simulated cohort consisted of women aged 50 to 70 years at screening.ExposuresMammography screening at 1 to 6 yearly screening intervals based on breast cancer risk and standard care (screening every 3 years).Main outcomes and measuresIncremental net monetary benefit based on quality-adjusted life-years (QALYs) and National Health Service (NHS) costs (given in pounds sterling; to convert to US dollars, multiply by 1.28).ResultsArtificial intelligence-based risk-stratified programs were estimated to be cost-saving and increase QALYs compared with the current screening program. A screening schedule of every 6 years for lowest-risk individuals, biannually and triennially for those below and above average risk, respectively, and annually for those at highest risk was estimated to give yearly net monetary benefits within the NHS of approximately £60.4 (US $77.3) million and £85.3 (US $109.2) million, with QALY values set at £20 000 (US $25 600) and £30 000 (US $38 400), respectively. Even in scenarios where decision-makers hesitate to allocate additional NHS resources toward screening, implementing the proposed strategies at a QALY value of £1 (US $1.28) was estimated to generate a yearly monetary benefit of approximately £10.6 (US $13.6) million.Conclusions and relevanceIn this decision analytical model study of integrating risk-stratified screening with a breast cancer AI model into the UK National Breast Cancer Screening Program, risk-stratified screening was likely to be cost-effective, yielding added health benefits at reduced costs. These results are particularly relevant for health care settings where resources are under pressure. New studies to prospectively evaluate AI-guided screening appear warranted.

Project description:ObjectivesProposals to stratify breast screening by breast cancer risk aim to produce a better balance of benefits to harms. Notably, risk estimation calculated from common risk factors and a polygenic risk score would enable high-risk women to benefit from more frequent screening or preventive medication. This service would also identify low-risk women who experience fewer benefits from attending, as lower grade and in situ cancers may be treated unnecessarily. It may therefore be appropriate for low-risk women to attend screening less. This study aimed to elicit views regarding implementing less frequent screening for low-risk women from healthcare professionals who implement risk-stratified screening.MethodsHealthcare professionals involved in the delivery of risk-stratified breast screening were invited to participate in a focus group within the screening setting in which they work or have a telephone interview. Primary care staff were also invited to provide their perspective. Three focus groups and two telephone interviews were conducted with 28 healthcare professionals. To identify patterns across the sample, data were analysed as a single dataset using reflexive thematic analysis.ResultsAnalysis yielded three themes: Reservations concerning the introduction of less frequent screening, highlighting healthcare professionals' unease and concerns towards implementing less frequent screening; Considerations for the management of public knowledge, providing views on media impact on public opinion and the potential for a low-risk pathway to cause confusion and raise suspicion regarding implementation motives; and Deliberating service implications and reconfiguration management, where the practicalities of implementation are discussed.ConclusionsHealthcare professionals broadly supported less frequent screening but had concerns about implementation. It will be essential to address concerns regarding risk estimate accuracy, healthcare professional confidence, service infrastructure and public communication prior to introducing less frequent screening for low-risk women.

Dataset Information

Should Age-Dependent Absolute Risk Thresholds Be Used for Risk Stratification in Risk-Stratified Breast Cancer Screening?

Publications

Should Age-Dependent Absolute Risk Thresholds Be Used for Risk Stratification in Risk-Stratified Breast Cancer Screening?

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