Two view mammography at incident screens: cost effectiveness analysis of policy options

BMJ 1999;319:1097-1102 ( 23 October )

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Two view mammography at incident screens: cost effectiveness analysis of policy options

Katharine Johnston, research fellow, ^a Jackie Brown, senior research fellow. ^b

^a Health Economics Research Centre, University of Oxford, Institute of Health Sciences, Headington, Oxford OX3 7LF, ^b Health Economics Research Group, Brunel University, Uxbridge, Middlesex UB8 3PH

Correspondence to: K Johnston kathy.johnston{at}ihs.ox.ac.uk

Objective: To determine the cost effectiveness of twoview mammography at incidentscreens.
Design: Incremental cost effectiveness analyses recognisingdifferences in current reading policy, based on effectivenessdata from an observationalstudy.
Setting: Breast screening programmes in England andWales.
Main outcome measures: Health service costs, cancers detected, incrementalcost effectiveness ratios per cancer detected, whole time equivalentstaff.
Results: For programmes currently using one view withsome form of double reading, the incremental cost effectivenessratio of two view mammography at incident screens ranged between£6589 and £6716, depending on the reading policy. For programmescurrently using one view with single reading, two policy optionswere found to be more efficient than two view single reading:one view with double reading (arbitration; incremental cost effectivenessratio of £210) and two view double reading (arbitration). If programmesusing one view with single reading changed to double reading (arbitration)and then subsequently to two views double reading (arbitration),additional cancers could be detected with an incremental costeffectiveness ratio of £7983. The implementation cost of two viewmammography at incident screens in programmes in England and Waleswould be £2.9 million and would require 13.4 whole time equivalentradiologists.
Conclusions: The cost effectiveness of two view mammographyat incident screens depends on the film reading policy. A policyof two view mammography at incident screens in England and Waleswould be efficient only if programmes using single reading movedto double reading. Given limited resources, priority should begiven to introducing double reading in the subset of programmescurrently using single reading as this requires fewer additionalradiologists and is more costeffective.

Key messages

The NHS breast screening programme is currently considering whether to introduce two view mammography at incident (subsequent) screens in England and Wales
As individual screening programmes operate different reading policies it is important to recognise that both two views and double reading may independently increase the cancer detection rate and thus affect cost effectiveness
A policy of two view mammography at incident screens is efficient only if programmes that use single reading also move to double reading
Implementation of two view mammography at incident screens in programmes in England and Wales would cost £2.9 million and require 13.4 whole time equivalent radiologists
Given the current shortage of radiologists, priority should be given to introducing double reading in the subset of programmes currently using single reading as this requires fewer additional radiologists and is more cost effective

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