Breast cancer screening in Europe and China: strategy evaluation and optimization

Recently, female breast cancer has replaced lung cancer as the most frequently diagnosed cancer worldwide. In the Netherlands, where population-based screening programs have been introduced decades ago, a proper evaluation of current breast cancer screening programs and the exploration of new screening strategies and modalities are essential to improve the effectiveness of screening in the general population. However, for developing countries such as China, more studies are required on whether and how to implement a national screening program. This thesis aimed therefore to provide evidence on the improvement of breast cancer screening practices in both the Netherlands and China. Our results showed that simulation models are of vital use in the evaluation and optimization of screening strategies, and by incorporating mammographic sensitivity as a continuous function of tumour size and breast density, the performance of a cost-effectiveness simulation model can be further improved. For the Netherlands, a stratified breast cancer screening strategy based on breast density can be a further improvement, and advanced screening modalities such as digital breast tomosynthesis and abbreviated-protocol MRI could be used as a cost-effective alternative to mammography in women with dense or extremely dense breasts. For urban China we found that mammography should be considered as a more favourable screening method than ultrasound, and that biennial mammography screening from age 45-70 years old is economically attractive. For rural China, accessible and affordable health care and improved breast cancer awareness are of higher priority given the relatively lower breast cancer incidence rate.