Cost-Effectiveness of COG Breast Cancer Screening Guidelines for Hodgkin Lymphoma Survivors Who Received Chest Irradiation

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In a cost-effective analysis reported in the Journal of Clinical Oncology, Wong et al found that only the mammography component of the Children’s Oncology Group (COG) breast cancer screening guidelines for chest-irradiated Hodgkin lymphoma survivors was cost-effective; magnetic resonance imaging (MRI) was not cost-effective at current costs. The COG guidelines recommend annual mammography and breast MRI in this setting.

Study Details

Breast cancer risks and non–breast cancer mortality were estimated from female 5-year survivors of Hodgkin lymphoma in the Childhood Cancer Survivor Study and the U.S. population. Performance of mammography and MRI were derived from studies in Hodgkin lymphoma. Outcomes at ages 25 to 74 years were estimated by microsimulation modeling. Costs were expressed in 2017 U.S. dollars.

Key Findings

On the assumption of 100% screening adherence, annual breast cancer screening extended life-years by 0.34 to 0.46 years vs no screening. Based on a willingness-to-pay threshold to gain a quality-adjusted life-year of incremental cost-effectiveness ratio (ICER) < $100,000, annual mammography at age 25 to 74 years was the only cost-effective strategy (ICER = $58,726).  

In analysis adjusted for reduced adherence (moderate adherence: 65% of survivors with 100% adherence, 25% with 50% adherence, and 10% with 0% adherence), only annual mammography at age 30 to 74 years was cost-effective (ICER = $56,972).  

Annual mammography supplemented with MRI costing $545 was not cost-effective under either adherence condition, with a willingness-to-pay threshold of > $250,000 being required to consider MRI cost-effective.

If MRI cost were reduced to $300, supplemental MRI would become more cost-effective, particularly in the moderate adherence scenario. On the assumption of 100% adherence, the ICER for annual mammography at age 25 to 74 years with biennial MRI at age 30 to 64 years would be $157,520. On the assumption of moderate adherence, the ICER for annual mammography and MRI at age 30 to 74 years would be $133,682.

The investigators concluded, “Annual breast cancer screening using mammography at age 30 to 74 years is effective and cost-effective in female chest-irradiated Hodgkin lymphoma survivors. Although annual adjunct MRI is not cost-effective at $545 U.S. dollars cost, it could become cost-effective as MRI cost is reduced, a plausible scenario with the emergent use of abbreviated MRI.

F. Lennie Wong, PhD, of the Department of Cancer Control and Population Sciences, City of Hope Comprehensive Cancer Center, is the corresponding author for the Journal of Clinical Oncology article.

Disclosure: The study was supported by the American Cancer Society, National Cancer Institute, and others. For full disclosures of the study authors, visit

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