• ShihYa-Chen TinaYTThe University of Texas MD Anderson Cancer Center, Houston, Texas (Y.T.S., W.D., Y.X., Y.S.)., Wenli Dong, Ying Xu, Ruth Etzioni, and Yu Shen.
• The University of Texas MD Anderson Cancer Center, Houston, Texas (Y.T.S., W.D., Y.X., Y.S.).
• Ann. Intern. Med. 2021 May 1; 174 (5): 602612602-612.

BackgroundBreast density classification is largely determined by mammography, making the timing of the first screening mammogram clinically important.ObjectiveTo evaluate the cost-effectiveness of breast cancer screening strategies that are stratified by breast density.DesignMicrosimulation model to generate the natural history of breast cancer for women with and those without dense breasts and assessment of the cost-effectiveness of strategies tailored to breast density and nontailored strategies.Data SourcesModel parameters from the literature; statistical modeling; and analysis of Surveillance, Epidemiology, and End Results-Medicare data.Target PopulationWomen aged 40 years or older.Time HorizonLifetime.PerspectiveSocietal.InterventionNo screening; biennial or triennial mammography from age 50 to 75 years; annual mammography from age 50 to 75 years for women with dense breasts at age 50 years and biennial or triennial mammography from age 50 to 75 years for those without dense breasts at age 50 years; and annual mammography at age 40 to 75 years for women with dense breasts at age 40 years and biennial or triennial mammography at age 50 to 75 years for those without dense breasts at age 40 years.Outcome MeasuresLifetime costs and quality-adjusted life-years (QALYs), discounted at 3% annually.Results Of Base Case AnalysisBaseline screening at age 40 years followed by annual screening at age 40 to 75 years for women with dense breasts and biennial screening at age 50 to 75 years for women without dense breasts was effective and cost-effective, yielding an incremental cost-effectiveness ratio of $36 200 per QALY versus the biennial strategy at age 50 to 75 years.Results Of Sensitivity AnalysisAt a societal willingness-to-pay threshold of $100 000 per QALY, the probability that the density-stratified strategy at age 40 years was optimal was 56% compared with 6 other strategies.LimitationFindings may not be generalizable outside the United States.ConclusionThe study findings advocate for breast density-stratified screening with baseline mammography at age 40 years.Primary Funding SourceNational Cancer Institute.

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