Breast Cancer Screening: Trade-offs in Planning and Service Provision Short Title: Trade-offs in Breast Cancer Screening

This work combines and extends previous work on breast cancer screening models by explicitly incorporating, for the time, the dynamics of health care states, program outreach, and the screening volume-quality relationship in a service system model to examine the effect of public health policy and service capacity decisions on public health outcomes. We consider the impact of increasing standards for minimum reading volume to improve quality, expanding outreach with or without decentralization of service facilities, and the potential of queueing due to stochastic effects and limited capacity. The results indicate a strong relation between screening quality and the cost of screening and treatment, and emphasize the importance of accounting for service dynamics when assessing the performance of health care interventions. For breast cancer screening, increasing outreach without improving quality and maintaining capacity results in less than predicted by standard models.