{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T12:33:24Z","timestamp":1793363604661,"version":"4.5.0"},"reference-count":49,"publisher":"Public Library of Science (PLoS)","issue":"3","license":[{"start":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T00:00:00Z","timestamp":1773273600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Early detection through breast cancer screening significantly enhances survival rates and reduces mortality. However, financial constraints in low- and middle-income countries often limit the implementation of large-scale screening programs. This study evaluates the cost-effectiveness of a combined Clinical Breast Examination (CBE), Breast Ultrasound (BUS), and supplementary Mammography (MAM), screening strategy for women aged 35\u201365 in Shenzhen, China. It further identifies optimal screening protocols by analyzing variations in screening frequency, starting\/ending ages, and long-term health outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A Markov model was developed from a societal perspective to assess the lifetime cost-effectiveness of biennial (CBE\u2009+\u2009BUS)+MAM screening for women aged 35\u201365. A total of 27 strategies were simulated, varying screening frequency (annual, biennial, triennial), age at initiation (35, 40, 45), age at cessation (65, 69, 70), and modality combinations. Quality-Adjusted Life Years (QALYs) served as the primary health outcome metric. Incremental Cost-Utility Ratios (ICURs) were calculated, with one-way and second-order Monte Carlo sensitivity analyses conducted to evaluate parameter uncertainty.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 699,600 participants, 724 breast cancer cases were detected (detection rate: 103.49 per 100,000), with 88% diagnosed at early stages. The current Shenzhen strategy \u2013 biennial Clinical Breast Examination combined with Breast Ultrasound and supplementary Mammography ((CBE\u2009+\u2009BUS)+MAM\/2year\/35_65) \u2013 demonstrated an ICUR of 140,915 CNY\/QALY compared to no screening, below one times the per capita GDP (indicating cost-effectiveness). In various scenarios, while the (CBE\u2009+\u2009BUS)+MAM\/3year\/45_65 strategy had a lower ICUR (95,545 CNY\/QALY), the ICUR for the current strategy versus this alternative was 518,121 CNY\/QALY, still below the willingness-to-pay threshold of 537,000 CNY (three times GDP). Second-order Monte Carlo simulations confirmed the robustness of the current strategy in 76% of scenarios.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The (CBE\u2009+\u2009BUS) +MAM\/2year\/35_65 strategy was identified as the optimal choice among 27 alternatives, providing a cost-effective balance between early detection and resource efficiency. This evidence solidifies its use and offers a strategic framework for allocating public health resources in Shenzhen and comparable urban settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0344253","type":"journal-article","created":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T17:39:30Z","timestamp":1773337170000},"page":"e0344253","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["A cost-effective breast cancer screening strategy for Urban China: Findings from a Shenzhen-based modeling study"],"prefix":"10.1371","volume":"21","author":[{"given":"Changqing","family":"Tu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuke","family":"Zhong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huan","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haifeng","family":"Qi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qian","family":"Lu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-1027-4673","authenticated-orcid":true,"given":"Xuesen","family":"He","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,3,12]]},"reference":[{"issue":"3","key":"pone.0344253.ref001","first-page":"229","article-title":"Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries","volume":"74","author":"F Bray","year":"2024","journal-title":"CA: a cancer journal for clinicians"},{"issue":"1","key":"pone.0344253.ref002","first-page":"47","article-title":"Cancer incidence and mortality in China, 2022","volume":"4","author":"B Han","year":"2024","journal-title":"J Natl Cancer Cent"},{"issue":"4","key":"pone.0344253.ref003","doi-asserted-by":"crossref","first-page":"465","DOI":"10.1001\/jamaoncol.2022.7826","article-title":"Estimates and Projections of the Global Economic Cost of 29 Cancers in 204 countries and territories from 2020 to 2050","volume":"9","author":"S Chen","year":"2023","journal-title":"JAMA Oncol"},{"issue":"9","key":"pone.0344253.ref004","first-page":"1735","article-title":"Unbalanced treatment costs of breast cancer in China: Implications From the Direct Costs of Inpatient and Outpatient Care in Liaoning Province","volume":"11","author":"Z Ma","year":"2022","journal-title":"Int J Health Policy Manag"},{"key":"pone.0344253.ref005","doi-asserted-by":"crossref","unstructured":"Dizon DS, Kamal AH. 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Wang","year":"2022","journal-title":"Thorac Cancer"},{"issue":"1","key":"pone.0344253.ref009","first-page":"33","article-title":"Breast cancer screening: Common questions and answers","volume":"103","author":"M Khan","year":"2021","journal-title":"Am Fam Physician"},{"issue":"15","key":"pone.0344253.ref010","doi-asserted-by":"crossref","first-page":"1599","DOI":"10.1001\/jama.2015.12783","article-title":"Breast cancer screening for women at average risk: 2015 Guideline update from the american cancer society","volume":"314","author":"KC Oeffinger","year":"2015","journal-title":"Jama"},{"issue":"4","key":"pone.0344253.ref011","doi-asserted-by":"crossref","first-page":"306","DOI":"10.1097\/CEJ.0b013e3282f0c0cc","article-title":"The effect of service screening on breast cancer mortality rates","volume":"17","author":"B Cox","year":"2008","journal-title":"Eur J Cancer 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women","volume":"110","author":"IOL Wong","year":"2007","journal-title":"Cancer"},{"issue":"9","key":"pone.0344253.ref022","first-page":"1658","article-title":"Assessment of the benefits and cost-effectiveness of population-based breast cancer screening in Urban China: A model-based analysis","volume":"11","author":"J Wang","year":"2022","journal-title":"Int J Health Policy Manag"},{"key":"pone.0344253.ref023","unstructured":"National Health Commission of the People\u2019s Republic of China. China Health Statistical Yearbook 2022. 2022. http:\/\/www.nhc.gov.cn\/mohwsbwstjxxzx\/tjtjnj\/202305\/6ef68aac6bd14c1eb9375e01a0faa1fb.shtml"},{"key":"pone.0344253.ref024","doi-asserted-by":"crossref","first-page":"39459","DOI":"10.1038\/srep39459","article-title":"Preliminary effectiveness of breast cancer screening among 1.22 million Chinese females and different cancer patterns between urban and rural women","volume":"6","author":"Y Huang","year":"2016","journal-title":"Sci Rep"},{"issue":"12","key":"pone.0344253.ref025","first-page":"1665","article-title":"Cost-effectiveness of multiple screening modalities on breast cancer in Chinese women from Shanghai","volume":"38","author":"F Wu","year":"2017","journal-title":"Zhonghua liu xing bing xue za zhi = Zhonghua liuxingbingxue zazhi"},{"issue":"6","key":"pone.0344253.ref026","doi-asserted-by":"crossref","first-page":"593","DOI":"10.1016\/0021-9681(87)90019-1","article-title":"Utility approach to measuring health-related quality of life","volume":"40","author":"GW Torrance","year":"1987","journal-title":"J Chronic Dis"},{"issue":"2","key":"pone.0344253.ref027","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1590\/S1020-49892002000800017","article-title":"Macroeconomics and health: Investing in health for economic development","volume":"12","author":"JD Sachs","year":"2002","journal-title":"Rev Panam Salud Publica"},{"issue":"1","key":"pone.0344253.ref028","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1111\/j.1524-4733.2005.08101.x","article-title":"Probabilistic analysis of cost-effectiveness models: Statistical representation of parameter uncertainty","volume":"8","author":"A Briggs","year":"2005","journal-title":"Value Health"},{"issue":"3","key":"pone.0344253.ref029","first-page":"3","article-title":"Parameter distribution of associated parameters in probability sensitivity analysis of pharmacoeconomic evaluation","volume":"37","author":"W Xiaomin","year":"2018","journal-title":"Chinese 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Mukama","year":"2020","journal-title":"JAMA Oncol"},{"issue":"2","key":"pone.0344253.ref040","doi-asserted-by":"crossref","DOI":"10.1148\/rycan.229003","article-title":"An evidence-based and inclusive breast cancer screening strategy: Summary of Current Guidelines from the American College of Radiology and Society of Breast Imaging","volume":"4","author":"D Diwanji","year":"2022","journal-title":"Radiol Imaging Cancer"},{"issue":"4","key":"pone.0344253.ref041","doi-asserted-by":"crossref","first-page":"653","DOI":"10.1158\/1055-9965.EPI-20-1230","article-title":"Cost-effectiveness Analysis of Breast Cancer Screening Using Mammography in Singapore: A modeling study","volume":"30","author":"S Chootipongchaivat","year":"2021","journal-title":"Cancer Epidemiol Biomarkers Prev"},{"issue":"1","key":"pone.0344253.ref042","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1038\/s41523-021-00295-9","article-title":"Effectiveness of the Korean National Cancer Screening Program in reducing 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Med"},{"issue":"339","key":"pone.0344253.ref046","first-page":"423","article-title":"Experiences of patients with false positive results from colorectal cancer screening","volume":"40","author":"D Mant","year":"1990","journal-title":"Br J Gen Pract"},{"issue":"3","key":"pone.0344253.ref047","doi-asserted-by":"crossref","first-page":"170","DOI":"10.1093\/jnci\/djp482","article-title":"Ductal carcinoma in situ of the breast: A systematic review of incidence, treatment, and outcomes","volume":"102","author":"BA Virnig","year":"2010","journal-title":"J Natl Cancer Inst"},{"issue":"2","key":"pone.0344253.ref048","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1016\/j.jtbi.2004.08.002","article-title":"Evaluation of pathways for progression of heterogeneous breast tumors","volume":"232","author":"L Sontag","year":"2005","journal-title":"J Theor 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