Flexible transition probability model for assessing cost-effectiveness of breast cancer screening extension to include women aged 45-49 and 70-74.

Breast cancer is the most common cancer among Western women. Fortunately, organized screening has reduced breast cancer mortality. New recommendation by the European Union suggests extending screening with mammography from 50-69-year-old women to 45-74-year-old women. However, before extending screening to new age groups, it's essential to carefully consider the benefits and costs locally as circumstances vary between different regions and/or countries. We propose a new approach to assess cost-effectiveness of breast cancer screening for a long-ongoing program with incomplete historical screening data. The new model is called flexible stage distribution model. It is based on estimating the breast cancer incidence and stage distributions of breast cancer cases under different screening strategies. The model parameters, for each considered age group, include incidence rates under screening/non-screening, probability distribution among different stages, survival by stages, and treatment costs. Out of these parameters, we use the available data to estimate survival rates and treatment costs, while the modelling is done for incidence rates and stage distributions under screening policies for which the data is not available. In the model, an ongoing screening strategy may be used as a baseline and other screening strategies may be incorporated by changes in the incidence rates. The model is flexible, as it enables to apply different approaches for estimating the altered stage distributions. We apply the proposed flexible stage distribution model for assessing incremental cost of extending the current biennial breast cancer screening to younger and older target ages in Finland.