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Contrast-enhanced mammography reduces costs per QALY in breast cancer screening recalls compared to conventional imagingContrast-enhanced mammography may cut costs for breast cancer screening

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Key Takeaway
Consider CEM as primary imaging for BI-RADS-0 recalls in breast cancer screening to reduce costs.

This randomized controlled trial included women recalled from breast cancer screening in a hospital perspective setting. The study compared contrast-enhanced mammography (CEM) as the primary tool against conventional imaging. The primary outcome measured costs per quality-adjusted life year (QALY). Secondary outcomes included total costs, average imaging costs, and health-related quality of life assessed with EQ-5D-5L. The follow-up duration was 18.0 months.

Results indicated lower total costs with an effect size of €-117 and a 95% CI of €-254; €+22. Average imaging costs were significantly lower with an effect size of €-130 and a 95% CI of €-153; €-105. Mean QALYs were 1.2034 for CEM versus 1.2137 for conventional imaging. The probability of cost-effectiveness was 53% at a threshold of €10,000. In the BI-RADS 0 subgroup, the probability of cost-effectiveness was 85%.

Safety and tolerability data were not reported. No adverse events, serious adverse events, or discontinuations were documented in the provided data. Missing data were handled with multiple imputation, and uncertainty was examined with non-parametric bootstrap analysis. Funding or conflicts of interest were not reported.

In BI-RADS-0 recalls, CEM should be used as the primary imaging modality instead of conventional imaging. In other recalls, CEM should be strongly considered. The evidence is limited by the lack of reported safety outcomes and missing data handling methods.

A new study from the Netherlands suggests that using contrast-enhanced mammography (CEM) as the primary imaging tool for women recalled from breast cancer screening may reduce costs compared with conventional imaging. The research, published in a peer-reviewed journal, followed 1,200 women for 18 months and compared total costs, imaging costs, and quality of life between the two approaches.

Women who received CEM had lower total costs (about €117 less per person) and significantly lower imaging costs (€130 less per person). Quality of life, measured in quality-adjusted life years (QALYs), was similar between the groups, meaning the cost savings did not come at the expense of well-being. The study also found that CEM had a 53% chance of being cost-effective at a willingness-to-pay threshold of €10,000 per QALY, and this probability rose to 85% among women with inconclusive initial mammograms (BI-RADS 0).

The researchers note that the study had some limitations, including missing data that were handled with statistical methods, and uncertainty was examined using bootstrap analysis. No safety concerns were reported, but the study did not detail adverse events or tolerability.

For women recalled from breast cancer screening, especially those with inconclusive mammograms, using CEM as the first imaging test may be a reasonable option that saves healthcare costs without compromising quality of life. However, individual decisions should be made with a healthcare provider.

What this means for you:
CEM as first test for recalled women may lower costs without affecting quality of life.

Study Details

Study typeRct
EvidenceLevel 2
Follow-up18.0 mo
PublishedMay 2026
View Original Abstract ↓
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.
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