Breast Cancer Screening Using Clinical Breast Examination: A Cost-Effectiveness Analysis for South Africa

Objectives: The World Health Organization emphasizes screening and early diagnosis to reduce advanced cancer incidence and mortality. In low-to-middle-income countries, breast cancer survival rates are low because of late detection. South Africa's policy recommends twice-yearly clinical breast examinations (CBEs) for asymptomatic women aged 40 to 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 [ie, 5% increase annually]) and scenario 2 (75% coverage by year 5, [ie, 17.5% increase annually]). A cohort model tracked women from screening to diagnosis, estimating downstaging's impact on breast cancer 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 1000 women screened for scenarios 1 and 2, respectively. Scenario 1 reduced breast cancer mortality by 0.7% and scenario 2 by 2.3%. Compared with no screening, the current baseline screening program averts 1645 disability-adjusted life years (DALYs) at $20,341/DALY averted. Scenario 1 averted 3823 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.