Health-economic evaluation of extended age ranges and increased participation in breast cancer screening in four major European countries

Breast cancer is the most commonly diagnosed cancer and a leading cause of cancer mortality among women in Europe. National population-based breast cancer screening programs using mammography reduces breast cancer mortality and are widely implemented across Europe, although substantial differences remain in screening coverage and organization, as well as the participation in opportunistic screening. In 2003, the Council of the European Union recommended biennial, organized population-based mammography screening for women aged 50–69 years, while in 2022, the recommended age range was extended to 45–74 years. Despite the recommendations of the EU council, screening practices still vary across EU countries. France currently screens women aged 50–74 and is investigating lowering the starting age. Germany extended its upper age limit to 75 in 2024, while lowering the starting age to 45 has been approved, but reimbursement and rollout are pending. In Italy, several regions already include women aged 45–49 and 70–74, and the 2026 budget law provides funding to extend screening nationally to these age groups. Spain’s national program covers women aged 50–69, although several regions have extended age limits. Participation is a key determinant of screening effectiveness and cost-effectiveness, yet rates remain below the desired 75% threshold in France (47%), Germany (52%), Italy (55%), and Spain (69%). Objective The aim of this study is to evaluate the health effects, costs, productivity losses, and cost-effectiveness of extending the national breast cancer screening program age range to 45–74 years and increasing participation rates to 75% in national screening programs in France, Germany, Italy, and Spain. Methods The study used a prevalence-based approach from a societal perspective to assess the one-year costs and health effects of breast cancer screening among women aged 45–74 years in France, Germany, Italy, and Spain. Using a decision-analytic model, five scenarios were compared with current practice: lowering the minimum screening age, raising the maximum screening age, adjusting both age limits, increasing participation, and combining all changes. Results In the combined scenario of extended age ranges and increased participation, the estimated number of lives saved annually were 721 in France, 1,342 in Germany, 849 in Italy, and 297 in Spain. Across the four countries, this corresponded to more than 3,200 lives saved annually and a 9.3% reduction in total breast cancer mortality. Increasing participation to 75% had the greatest impact on breast cancer mortality in France, Germany, and Italy, whereas raising the upper screening age to 74 years had the greatest impact on mortality in Spain, where the current participation rate is already 69%. These annual health gains were estimated to increase healthcare costs by €662 million, as €749 million in additional screening costs were partly offset by €87 million in lower treatment costs. Productivity losses were estimated to decrease by €142 million, resulting in a net increase in societal costs of €519 million. The incremental cost-effectiveness ratios for all scenarios were below the estimated country-specific willingness-to-pay thresholds from both payer and societal perspectives, except for lowering the starting age in Spain. Conclusion Expanding the age ranges of the national breast cancer screening programs was estimated to save additional lives, but increasing participation among women already eligible for screening resulted in the greatest reduction in breast cancer mortality and was the most cost-effective strategy. Policymakers should therefore prioritize measures to improve access, equity, and engagement in breast cancer screening programs, while ensuring that healthcare facilities receive sufficient resources to accommodate screening expansion.