Breast cancer screening using clinical breast examination: A cost-effectiveness analysis for South Africa

Introduction: WHO emphasises screening and early diagnosis to reduce advanced cancer incidence and mortality. In low- to middle-income countries, breast cancer (BC) survival rates are low because of late detection. South Africa's policy recommends twice-yearly clinical breast examinations (CBEs) for asymptomatic women aged 40-69. We assessed the impact of scaling up CBE screening on mortality and cost-effectiveness. Methods: Using trial data on downstaging, we compared the current baseline (5% coverage) with Scenario 1 (25% coverage by year 5, i.e. 5% increase annually) and Scenario 2 (75% coverage by year 5, i.e. 17.5% increase annually). A cohort model tracked women from screening to diagnosis, estimating downstaging’s impact on BC cases over their lifetime. Costs from the healthcare payer’s perspective are presented in 2022 US dollars. Results: Five-year screen detection rates were 2.39 and 2.08 per 1,000 women screened for Scenarios 1 and 2, respectively. Scenario 1 reduced BC mortality by 0.7% and Scenario 2 by 2.3%. Compared to no screening, the current baseline screening program averts 1,645 DALYs at $20,341/DALY averted. Scenario 1 averted 3,823 DALYs with economic efficiency improving to $17,776/DALY averted, whereas Scenario 2 averted 12,165 DALYs at $19,552/DALY averted. Conclusions: CBE scale-up effectively saves life years but is not cost effective under the country’s opportunity cost-derived threshold of $3,015/DALY averted. However, decisions on the best screening policy are not solely based on cost-effectiveness. They involve careful consideration of budgetary constraints and competing healthcare priorities. Scale-up should consider system capacity, minimum care standards and cost-effective early detection strategies.