Long-Term Outcomes and Cost-effectiveness of Breast Cancer Screening With Digital Breast Tomosynthesis in the United States

Kathryn P. Lowry; Amy Trentham-Dietz; Clyde B. Schechter; Oguzhan Alagoz; William E. Barlow; Elizabeth S. Burnside; Emily F. Conant; John M. Hampton; Hui Huang; Karla Kerlikowske; Sandra J. Lee; Diana L. Miglioretti; Brian L. Sprague; Anna N. A. Tosteson; Martin J. Yaffe; Natasha K. Stout


J Natl Cancer Inst. 2020;112(6):582-589. 

In This Article

Abstract and Introduction


Background: Digital breast tomosynthesis (DBT) is increasingly being used for routine breast cancer screening. We projected the long-term impact and cost-effectiveness of DBT compared to conventional digital mammography (DM) for breast cancer screening in the United States.

Methods: Three Cancer Intervention and Surveillance Modeling Network breast cancer models simulated US women ages 40 years and older undergoing breast cancer screening with either DBT or DM starting in 2011 and continuing for the lifetime of the cohort. Screening performance estimates were based on observational data; in an alternative scenario, we assumed 4% higher sensitivity for DBT. Analyses used federal payer perspective; costs and utilities were discounted at 3% annually. Outcomes included breast cancer deaths, quality-adjusted life-years (QALYs), false-positive examinations, costs, and incremental cost-effectiveness ratios (ICERs).

Results: Compared to DM, DBT screening resulted in a slight reduction in breast cancer deaths (range across models 0–0.21 per 1000 women), small increase in QALYs (1.97–3.27 per 1000 women), and a 24–28% reduction in false-positive exams (237–268 per 1000 women) relative to DM. ICERs ranged from $195 026 to $270 135 per QALY for DBT relative to DM. When assuming 4% higher DBT sensitivity, ICERs decreased to $130 533–$156 624 per QALY. ICERs were sensitive to DBT costs, decreasing to $78 731 to $168 883 and $52 918 to $118 048 when the additional cost of DBT was reduced to $36 and $26 (from baseline of $56), respectively.

Conclusion: DBT reduces false-positive exams while achieving similar or slightly improved health benefits. At current reimbursement rates, the additional costs of DBT screening are likely high relative to the benefits gained; however, DBT could be cost-effective at lower screening costs.


Digital mammography (DM) has largely been the standard of care for breast cancer screening in the United States in the 21st century.[1] In 2011, the Food and Drug Administration approved digital breast tomosynthesis (DBT) as a new breast imaging modality that reconstructs cross-sectional slices of the breast, minimizing soft-tissue overlap.[2,3] Multiple studies of DBT screening performance have observed improved recall rates and cancer detection rates when DBT is used in combination with standard DM[4–10] or synthetic 2-dimensional images reconstructed from the tomosynthesis acquisition[11,12] compared to DM alone. As a result, DBT has been swiftly adopted in clinical practice; in 2015, the Centers for Medicare and Medicaid Services approved reimbursement codes for DBT performed in addition to DM for routine screening, and by mid-2018 approximately 50% of Mammography Quality Standards Act–certified facilities reported having DBT units.[13]

Despite the widespread adoption of DBT into clinical practice, it is not yet known how this transition from DM to DBT will affect long-term costs and health benefits. A previous cost-effectiveness analysis demonstrated that the use of biennial DBT screening in women ages between 50 and 74 years with dense breasts is cost-effective.[14] However, to our knowledge, no prior studies have used simulation modeling to evaluate the use of DBT in the general screening population. A National Cancer Institute–funded randomized controlled trial is in progress to evaluate whether DBT screening in average-risk women reduces advanced-stage breast cancer incidence compared to DM alone, but long-term results will not be available for many years.[15] In the interim, the long-term screening outcomes and cost-effectiveness of the use of DBT for routine screening are uncertain.

We used three established breast cancer microsimulation models from the Cancer Intervention and Surveillance Modeling Network (CISNET) to predict the long-term impact of integrating DBT into breast cancer screening practices in the United States. By incorporating available data on DBT performance, we estimated the incremental effect of DBT on breast cancer mortality, false-positive screens, quality-adjusted life-years (QALYs), costs, and cost-effectiveness. The results provide preliminary information for physicians and policy makers about how the transition to DBT may affect the benefits, harms, and cost-effectiveness of breast cancer screening on a population level.