Report into ‘prevention, early detection and economic burden of breast cancer’

Recently, there have been controversies about the benefits, harms and cost-effectiveness of secondary breast cancer prevention measures (the principal form of which is population-based mammography), with some arguing that it leads to over-diagnosis causing unnecessary treatment costs as well as risks and worries for affected women.

Given this context, GE Healthcare commissioned Bengt Jönsson and Nils Wilking to produce a new review on the economic burden of breast cancer worldwide and, given the current debates regarding secondary prevention, the review focuses on the cost-effectiveness of these programs in particular.

• Breast cancer is a significant and growing threat for the developing world. Incidence of breast cancer is increasing rapidly in the developing world, and survival rates are lower due to late stage diagnosis of the disease and limited access to treatment
• According to the latest available data from 2008, 15 million years of healthy life was lost worldwide due to women dying early or being ill with breast cancer. (Source: http://globocan.iarc.fr)
• Women in Africa, China and the USA lost the most years of healthy life (Source: http://globocan.iarc.fr)
• Of the 15 million years of healthy life list globally more than three times as many years were lost due to dying than being ill with the disease (Source: http://globocan.iarc.fr)
• In countries like Africa, Russia, Mexico, Turkey and Saudi Arabia death accounts for up to seven times more healthy years lost than elsewhere in the world  (Source: http://globocan.iarc.fr)
• Particularly in developing countries, low consumer awareness of the benefits of screening, the impact of breast cancer and cultural barriers are causing women to present very late with their symptoms. 
• There is a lack of access to accurate and current data on breast cancer incidence and mortality, the economic burden of the disease and detailed patient linked data on the Due to high breast cancer incidence and death rates, the disease has a considerable impact on health care system costs and the wider economy. Recently, there have been controversies about the benefits, harms and cost-effectiveness of secondary breast cancer prevention measures (the principal form of which is population-based mammography), with some arguing that it leads to over-diagnosis causing unnecessary treatment costs as well as risks and worries for affected women.

A significant and growing threat for the developing world 

Although incidence rates of breast cancer are currently significantly higher in developed countries than developing countries (72 and 29 per 100,000 females, respectively,

in 2008), the review shows that incidence rates in developed countries such as the Nordics, US and Canada over the last two decades are stabilising or falling. Furthermore, death rates in these markets are decreasing. 

The picture in developing countries is very different. Here, incidence rates are increasing rapidly, particularly in parts of Asia. This is mainly due to increased life expectancy but also lifestyles changing to reflect those of developed countries, such as women having fewer children as well as hormonal interventions such as post-menopausal hormonal therapy. 

Such trends can already be seen in the middle-aged populations of China’s urban areas, where a 20-30% increase in breast cancer incidence has been documented over the past decades, although part of this increase may also be due to earlier diagnosis and better diagnostic methods such as the introduction of mammography. 

According to the most current data from 2008, 15 million years of healthy life were lost globally due to dying or being ill with the disease. ‘Healthy years lost’ are calculated by adding years of life lost due to premature death to the years of living incapacitated with the disease.

As the table below shows, women in Africa, China and the USA lost the most years of healthy life. Furthermore, of the 15 million years lost globally, more than three times as many years were lost due to dying than being ill with the disease. (This figure is calculated by adding together the figure for Years of Life Lost (YLL) with Years of Living with a Disability (YLD))

Meanwhile, for women in Africa, Russia, Mexico, Turkey and Saudi Arabia, the number of healthy years lost due to death were up to seven times greater than elsewhere in the world. 

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The disease and economic burden of breast cancer are high; it is the second most common cancer form overall and the most common cancer for women, constituting 25% of all female cancer.  The indirect costs of breast cancer are also greater than the direct costs of treatment as the disease affects many women during their productive years (under 65), resulting in working days lost.  For example, the report quotes one Swedish study that estimates costs linked to treatment, detection, prevention or care of breast cancer (direct costs) to be significant, but indirect costs of the disease (the cost of lost productivity due to the patients’ disability, illness and premature mortality) to be more than twice as large. 

The review finds strong evidence of the importance of early diagnosis and treatment for improved breast cancer survival.

Strong links are found between the stage at which breast cancer is diagnosed and country survival rates, suggesting that differences in early detection programs and access to appropriate diagnostics and treatment services are the cause. 

The review also highlights the economic benefits of early diagnosis, citing evidence from several studies which consistently find treatment costs for later stages (stage III and IV) are higher than for treatment of breast cancer in stage I and II. 

With regards to the value of breast cancer screening, the report concludes that while screening for breast cancer has a positive effect on mortality, confirming the results from clinical trials, this effect is smaller than those of improving treatment and other factors. These results emphasise the need to optimise screening programs further.

Particularly in developing countries, low consumer awareness of the benefits of screening, the impact of breast cancer and cultural barriers are causing women to present very late with their symptoms. For example, a recent survey in Mexico City is mentioned which indicates many women feel uncomfortable or worried about doing mammography. In another survey, it was found that among 1,000 Hong Kong Chinese women aged 18-69, almost 60% had never heard of mammography screening. This shows a need to increase consumer awareness and education efforts to ensure women do not die unnecessarily in these regions.

Accurate data on breast cancer incidence and mortality on the national level is lacking in a number of countries due to limited cancer registration and there is a need for more detailed patient linked data on outcome in relation to treatment patterns and stage of diagnosis to understand how changes in clinical practice affect outcome. There is also limited data collected on breast cancer patients’ quality of life following diagnosis and treatment and the report’s authors call on doctors to address this.