Extended cost effectiveness analysis of interventions for early detection, screening and breast cancer control: case studies of South Africa and Uganda

Abewe, Christabell

Extended cost effectiveness analysis of interventions for early detection, screening and breast cancer control: case studies of South Africa and Uganda

Thesis / Dissertation

2026

Publisher

University of Cape Town

Department

Health Economics Unit

Faculty

Faculty of Health Sciences

Abstract

The global statistics for the year 2022 indicate that female breast cancer is the second leading cause of global cancer incidence with an estimated 2.3 million cases and among women, it is the most frequently diagnosed cancer and the leading cause of cancer death among women in 157 countries [1]. In the African region, breast cancer incidence and mortality are on an upward trajectory and predicted to double in Sub-Saharan African by 2050. Given the growing burden of breast cancer in low- and middle-income countries (LMICs), these countries now face the challenge of effectively detecting and treating a disease that was previously considered too uncommon to merit the allocation of finite health care resources. As such, in LMICs there is a need to scale up early detection and screening strategies that can improve on the too common pattern of disease presentation at a stage when prognosis is very poor. We constructed a dynamic state transition model to estimate the cost effectiveness of three breast cancer down-staging interventions in Uganda and South Africa. Our model is premised on a comprehensive mathematical framework that estimates the stage shifts in early versus late stages of breast cancer diagnosis based on proportional performance rates of three early detection and screening interventions (awareness raising, clinical breast examination (CBE) and mammography) spanning 40 years. This study then used the extended cost effectiveness analysis framework to assess the possible distributional impact of utilizing universal public financing as a tool to increase access and coverage of breast cancer early detection interventions in these two countries. This dissertation found that biennial CBE and awareness raising interventions are not only crucial for down-staging breast cancer diagnosis, but they are also economically attractive and viable for options for both Uganda and South Africa. Biennial CBE coupled with treatment interventions for all stages was cost-effective for South Africa with an ICER of $2,708 per healthy life year gained. Awareness raising interventions were also found to be cost effective with an ICER of 3,201 per health life year gained. Mammography screening combined with treatment for all stages was not found to be a cost-effective intervention for South Africa with an ICER of $9,491 per healthy life year gained. For Uganda, we found awareness raising interventions to be the most cost-effective interventions for breast cancer control with a dominant ICER of $-118 per healthy life year gained. Biennial CBE for women aged 40-74 combined with treatment for all stages was also cost effective with an ICER of $416 per healthy life year gained. Biennial MMG screening combined with treatment for all stages was not cost effective with an ICER of $3,110 per healthy life year gained. Further, this thesis demonstrated that publicly financing early detection and screening interventions in LMICs for breast cancer can alleviate a considerable proportion of breast cancer burden and catastrophic health expenditures benefiting the poorest wealth quintiles. In South Africa 44% of the deaths averted are in the wealthiest two quintiles while the poorest two quintiles would account for 34% of the total deaths averted. Regarding financial protection, our analysis shows that publicly financing breast cancer control interventions could avert approximately US $7.89 million over the 40years, this translates to US $197,254 annually. The distribution of catastrophic health expenditures averted is pro-poor, with the poorest wealth quintile accounting for 76% of the averted catastrophic 2 health expenditure cases, on the other hand, the wealthiest two quintiles account for approximately 1.4% of the catastrophic health expenditure cases averted. In Uganda, our analysis shows that 55% of the deaths averted are concentrated in the wealthiest two quintiles while the poorest two quintiles would account for 26% of the total deaths averted. Regarding financial protection, our analysis shows that publicly financing breast cancer control interventions could avert approximately US $29.2 million over the 40-years, this translates to US$729,098 annually. The distribution of catastrophic health expenditures averted is pro-poor, with the lowest three wealth quintiles accounting for 63% of the catastrophic cases averted while the richest two quintiles account for 37% of the cases of catastrophic expenditures averted. The findings from this thesis are notable for breast cancer policy in LMICs as the analysis demonstrated significant down-staging associated with early detection and screening interventions for breast cancer. Implementation of these interventions will require substantial additional financial investments, but our analysis shows that the health benefits will broadly outweigh these requirements for CBE and awareness raising interventions.