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MRI screening for women with extremely dense breasts can be more cost-effective than biannual mammography, according to a Dutch study.

While screening every 2 years with mammography alone had the lowest total costs, it also resulted in only 47 quality-adjusted life years (QALY) gained. However, screening with MRI alone every 4 years was cost-effective and doubled the number of QALYs gained to 96, reported H. Amarens Geuzinge, MSc, of Erasmus University Medical Center in Rotterdam, The Netherlands, and colleagues.

When applying the National Institute for Health and Care Excellence (NICE) threshold of €22,000 ($25,500), quadrennial MRI had the highest acceptable incremental cost-effectiveness ratio (ICER), with €15,620 ($18,110) per QALY, and thus should be recommended from a cost-effectiveness perspective, the authors suggested in the .

"If decision makers are willing to pay more than €22,000 per QALY gained, MRI every 2 or 3 years can also become cost-effective," they added.

Screening every 3 years with MRI alone resulted in an ICER of €37,181 ($43,120) per QALY, they noted.

In an , Christiane K. Kuhl, MD, PhD, of University Hospital Aachen in Germany, and Pascal Baltzer, MD, PhD, of the Medical University of Vienna in Austria, noted that the study "provides critical evidence for a simple fact: A more sensitive and more expensive diagnostic test is cost-effective, even if it is used for screening, compared with a less sensitive and less expensive test."

"For women at risk of being underserved by mammographic screening, greater investment in breast cancer screening can be considered a useful investment in one's bodily health," they wrote.

Geuzinge and colleagues noted that the multicenter from 2019 demonstrated that additional MRI screening for women with extremely dense breast tissue resulted in fewer interval cancers, as well as the detection of smaller tumors, compared with screening with mammography alone. However, MRI screening also resulted in more false-positive results.

Thus, since MRI screening is more expensive than mammography, "a cost-effectiveness analysis is needed to evaluate whether the additional effects are worth the money," they wrote.

Using data from DENSE, the team simulated 10 different screening strategies involving mammography and MRI with varying intervals. The different strategies showed that:

• Biennial mammography alone resulted in 69 screen-detected breast cancers and 43 breast cancer deaths per 1,000 women
• Adding MRI every other screening round resulted in 24 additional screen-detected cancers and seven fewer breast cancer deaths
• Adding MRI every screening round resulted in another four additional screen-detected cancers and one fewer breast cancer death
• Leaving out mammography, MRI alone every 2 or 3 years yielded 100 and 97 screen-detected cancers, respectively
• Cases of overdiagnosis were similar across all strategies involving MRI (20-21 cases) versus 17 cases with biennial mammography alone
• Moving from the strategy consisting of alternating mammography and MRI at a 2-year interval to a more expensive strategy did not avert additional breast cancer deaths

Strategies involving mammography were inferior to others because they had more clinically diagnosed cancers, which resulted in more breast cancer deaths and less QALYs, compared with strategies that involved MRI, the authors observed.

However, alternating mammography and MRI every 2 years was efficient, and lengthening the intervals between MRI screenings resulted in lower total costs and only a few cancers not being screen-detected.

Geuzinge and colleagues pointed out that while MRI screening is cost-effective for women with dense breasts, they only make up about 8% of women ages 50 to 75. Therefore, MRI screening could be a burden on healthcare budgets.

"Furthermore, screening these women within a hospital setting may lead to capacity problems," they wrote. "Implementation of MRI screening would lead to a need of more MRI machines and more (trained) personnel."

In their editorial, Kuhl and Baltzer argued that a screening test that "predictably will not provide the expected diagnostic information is not only painfully disappointing for those who participated and still receive a late diagnosis of cancer but is a waste of money."

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