Investigating postmenopausal bleeding for endometiral cancer: cost-effectiveness of initial diagnostic strategies

Objective To determine the most cost- effective outpatient testing strategy for diagnosing endometrial cancer in women with postmenopausal bleeding ( PMB). Design Decision analysis modelling. Population Women with postmenopausal bleeding. Methods A decision analytic model was constructed to reflect current service provision, which evaluated 12 diagnostic strategies using endometrial biopsy ( EB), ultrasonography ( USS) ( 4- and 5- mm endometrial thickness cutoff) and hysteroscopy. Diagnostic probability estimates were derived from systematic quantitative reviews, clinical outcomes from published literature and cost estimates from local and NHS sources. Main outcome measures The cost per additional life year gained ( pound LYG) was determined and compared for each diagnostic strategy, and sensitivity analyses were performed. Results Compared with carrying out no initial investigation, a strategy based on initial diagnosis with USS using a 5- mm cutoff was the least expensive ( pound 11 470/ LYG). Initial investigation with EB or USS using a 4- mm cutoff was comparably cost- effective ( less than pound 30 000/ LYG versus USS with a 5- mm cutoff) at their most favourable diagnostic performance and at disease prevalence of 10% or more. The strategies involving initial evaluation with test combinations or hysteroscopy alone were not cost- effective. Conclusions Women presenting for the first time with PMB should undergo initial evaluation with USS or EB.