Contrast-enhanced mammography reduces costs per QALY in breast cancer screening recalls compared to conventional imaging

OBJECTIVE: The randomised controlled clinical RACER trial studied the diagnostic work-up with contrast-enhanced mammography (CEM) compared to conventional imaging as the primary tool in women recalled from breast cancer screening. This current trial-based economic evaluation was performed from a hospital perspective. MATERIALS AND METHODS: Cost prices were retrieved from the financial departments of the Maastricht University Medical Centre. Health-related quality of life was measured five times over 18 months using the EQ-5D-5L questionnaire. Cost-utility analysis outcome was expressed as costs per quality-adjusted life year (QALY). Multiple imputation was used for missing data, and non-parametric bootstrap analysis was performed to examine uncertainty in the difference in costs and incremental costs per QALY. Post hoc subgroup analysis was performed per BI-RADS recall score. RESULTS: Work-up with CEM showed lower total costs of €-117 (95% CI €-254; €+22) compared to conventional imaging. Average imaging costs were significantly lower with CEM (mean difference €-130; 95% CI €-153; €-105). Mean QALY for the CEM group was 1.2034 versus 1.2137 for the control group. Bootstrap analysis showed that 95% of all simulated ICERs were in the quadrants that indicate cost-savings, although 25% of the ICERs showed a small gain in QALY and 70% a small QALY loss. The probability of CEM being cost-effective is 53% at a threshold of €10,000 to accept a QALY loss. In the subgroup of BI-RADS 0 recalls, specifically, this probability is 85%. CONCLUSION: CEM as a primary tool in the diagnostic work-up is a cost-effective diagnostic strategy, especially in BI-RADS 0 recalls. KEY POINTS: Question Diagnostic accuracy is similar with contrast-enhanced mammography (CEM) compared to conventional as primary imaging. However, while the work-up is more efficient, is it also a cost-effective strategy? Findings Using CEM as primary imaging tool in the diagnostic work-up of recalls from screening results in lower costs with similar QALY compared to conventional imaging. Clinical relevance In BI-RADS- 0 (low suspicion) recalls, CEM should be used as primary imaging modality instead of conventional imaging. CEM compared to conventional imaging in the work-up of recalled women is cost-effective. In other recalls, CEM should be strongly considered.