Objective The randomised controlled clinical RACER trial studied the diagnostic work-up with contrast-enhanced mammography (CEM) compared to conventional imaging as the primary tool in women recalled from breast cancer screening. This current trial-based economic evaluation was performed from a hospital perspective. Materials and methods Cost prices were retrieved from the financial departments of the Maastricht University Medical Centre. Health-related quality of life was measured five times over 18 months using the EQ-5D-5L questionnaire. Cost-utility analysis outcome was expressed as costs per quality-adjusted life year (QALY). Multiple imputation was used for missing data, and non-parametric bootstrap analysis was performed to examine uncertainty in the difference in costs and incremental costs per QALY. Post hoc subgroup analysis was performed per BI-RADS recall score. Results Work-up with CEM showed lower total costs of €-117 (95% CI €-254; €+22) compared to conventional imaging. Average imaging costs were significantly lower with CEM (mean difference €-130; 95% CI €-153; €-105). Mean QALY for the CEM group was 1.2034 versus 1.2137 for the control group. Bootstrap analysis showed that 95% of all simulated ICERs were in the quadrants that indicate cost-savings, although 25% of the ICERs showed a small gain in QALY and 70% a small QALY loss. The probability of CEM being cost-effective is 53% at a threshold of €10,000 to accept a QALY loss. In the subgroup of BI-RADS 0 recalls, specifically, this probability is 85%. Conclusion CEM as a primary tool in the diagnostic work-up is a cost-effective diagnostic strategy, especially in BI-RADS 0 recalls. Key Points <Emphasis Type="BoldItalic">Question</Emphasis> Diagnostic accuracy is similar with contrast-enhanced mammography (CEM) compared to conventional as primary imaging. However, while the work-up is more efficient, is it also a cost-effective strategy? <Emphasis Type="BoldItalic">Findings</Emphasis> Using CEM as primary imaging tool in the diagnostic work-up of recalls from screening results in lower costs with similar QALY compared to conventional imaging. <Emphasis Type="BoldItalic">Clinical relevance</Emphasis> In BI-RADS- 0 (low suspicion) recalls, CEM should be used as primary imaging modality instead of conventional imaging. CEM compared to conventional imaging in the work-up of recalled women is cost-effective. In other recalls, CEM should be strongly considered. Graphical Abstract

Cost-effectiveness of contrast-enhanced mammography compared to conventional imaging in the work-up after screening (RACER trial)

期刊论文
发表日期：

2025年12月24日

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Lidewij M. F. H. Neeter,
Marc B. I. Lobbes,
Katya M. Duvivier,
H. P. J. Frank Raat,
Marjolein L. Smidt,
Joachim E. Wildberger,
Brigitte A. B. Essers

摘要

Objective

The randomised controlled clinical RACER trial studied the diagnostic work-up with contrast-enhanced mammography (CEM) compared to conventional imaging as the primary tool in women recalled from breast cancer screening. This current trial-based economic evaluation was performed from a hospital perspective.

Materials and methods

Cost prices were retrieved from the financial departments of the Maastricht University Medical Centre. Health-related quality of life was measured five times over 18 months using the EQ-5D-5L questionnaire. Cost-utility analysis outcome was expressed as costs per quality-adjusted life year (QALY). Multiple imputation was used for missing data, and non-parametric bootstrap analysis was performed to examine uncertainty in the difference in costs and incremental costs per QALY. Post hoc subgroup analysis was performed per BI-RADS recall score.

Results

Work-up with CEM showed lower total costs of €-117 (95% CI €-254; €+22) compared to conventional imaging. Average imaging costs were significantly lower with CEM (mean difference €-130; 95% CI €-153; €-105). Mean QALY for the CEM group was 1.2034 versus 1.2137 for the control group. Bootstrap analysis showed that 95% of all simulated ICERs were in the quadrants that indicate cost-savings, although 25% of the ICERs showed a small gain in QALY and 70% a small QALY loss. The probability of CEM being cost-effective is 53% at a threshold of €10,000 to accept a QALY loss. In the subgroup of BI-RADS 0 recalls, specifically, this probability is 85%.

Conclusion

CEM as a primary tool in the diagnostic work-up is a cost-effective diagnostic strategy, especially in BI-RADS 0 recalls.

Key Points

Question Diagnostic accuracy is similar with contrast-enhanced mammography (CEM) compared to conventional as primary imaging. However, while the work-up is more efficient, is it also a cost-effective strategy?

Findings Using CEM as primary imaging tool in the diagnostic work-up of recalls from screening results in lower costs with similar QALY compared to conventional imaging.

Clinical relevance In BI-RADS- 0 (low suspicion) recalls, CEM should be used as primary imaging modality instead of conventional imaging. CEM compared to conventional imaging in the work-up of recalled women is cost-effective. In other recalls, CEM should be strongly considered.

Graphical Abstract