Cost-Effectiveness of an Ultrasound-First Strategy in the Diagnostic Evaluation of Noncalcified Lesions Recalled From Screening Digital Breast Tomosynthesis

BACKGROUND. Ultrasound may be sufficient in the diagnostic evaluation of many noncalcified lesions recalled from screening digital breast tomosynthesis (DBT). In some scenarios, omission of diagnostic mammography can save health care costs. OBJECTIVE. The purpose of this study was to evaluate the cost-effectiveness of a strategy of performing ultrasound first versus diagnostic mammography first in the diagnostic evaluation of noncalcified lesions recalled from screening DBT. METHODS. Decision tree analysis was performed to compare ultrasound first versus diagnostic mammography first in the diagnostic evaluation of DBT-recalled noncalcified lesions from a U.S. health care system perspective with a 40-year horizon. The analysis used probabilities and prevalence information from published single-institution prospective data, additional literature-derived estimates of diagnostic test performance, and Medicare-allowable reimbursement rates. Health states were represented in a Markov chain model. For each strategy, the total cost and effectiveness (expressed in quality-adjusted life-years [QALYs]) were estimated. Cost-effectiveness was assessed through incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefit, with use of a willingness-to-pay (WTP) threshold of US$100,000 per QALY gained. Deterministic sensitivity analyses were performed to estimate the impact of different input parameters, and probabilistic sensitivity analysis with Monte Carlo simulations was conducted to estimate the impact of combined uncertainty across parameters. RESULTS. In the base-case scenario, for diagnostic evaluation of DBT-recalled noncalcified lesions, a strategy of performing ultrasound first versus diagnostic mammography first resulted in more cost savings (total cost, US$17,672 vs US$18,323) and greater cost-effectiveness (QALYs, 23.1309 vs 23.1306) over the 40-year horizon. The ultrasound-first strategy resulted in an ICER of -2,170,000 (expressed as U.S. dollars per QALY) and an incremental net monetary benefit of US$681 versus the diagnostic mammography-first strategy. Therefore, performing ultrasound first was deemed the more cost-effective strategy at the WTP threshold. In deterministic sensitivity analyses, the most important driver of cost-effectiveness was lost utility from delayed diagnosis, followed by the relative sensitivities of ultrasound and diagnostic mammography. In probabilistic sensitivity analysis, ultrasound first was the better strategy in 93.0% of iterations. CONCLUSION. A strategy of performing ultrasound first, with or without diagnostic mammography, is more cost-effective than a traditional strategy of conducting diagnostic mammography first. CLINICAL IMPACT. This cost-effectiveness analysis supports the growing prioritization of ultrasound as the primary method for evaluating DBT-recalled noncalcified lesions.