Frequent Mammography Screening for Breast Cancer Adds Billions to Cost

Rosemary Frei, MSc

May 2014, Vol 5, No 4 - Economics of Cancer Care

The total annual cost of mammography screening for women aged 40 to 85 years in the United States is estimated to be $7.8 billion, according to a new analysis (O’Donoghue C, et al. Ann Intern Med. 2014;160:145-153). That is $4.3 billion more than the cost would be if mammography intervals were lowered to fall in line with the recommendations of the US Preventive Services Task Force (USPSTF), the study researchers calculated.

Lead investigator Cristina O’Donoghue, MD, MPH, Resident in the Department of Surgery, University of Illinois at Chicago, and colleagues conducted the analysis to highlight the true aggregate cost to the US healthcare system of too-frequent mammography screening, in light of the many conflicting guidelines that have been published in the past few years and the ongoing debate on this topic.

“I’ve heard respected academics saying, ‘It’s only about $100 for a mammogram, it’s not expensive.’ But if it’s more than $4 billion more for the current screening approach compared with screening intervals recommended by the USPSTF, that’s a lot of money,” said Dr O’Donoghue. “If you had that money in your pocket, would you decide to screen annually, or do other things, such as make sure every woman has a breast cancer risk assessment?”

Dr O’Donoghue conducted the study with Laura J. Esserman, MD, MBA, Coleader, Breast Oncology Program, University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, and 2 other academics. The study was funded by the University of California, San Francisco, and the Safeway Foundation.

Study Details
The investigators created a simulation model of the cost of mammography at the rates that American women underwent breast cancer screening in 2010. They then compared the model to their estimates of the cost of 3 other screening-rate strategies, including (1) an annual screening starting at age 40 years and ending at age 84 years, as recommended by the American Cancer Society, the American College of Radiology, and other organizations; (2) biennial screening of women aged 50 to 70 years, which is the European approach; and (3) the current USPSTF recommendations, which comprise risk-based screening for women aged 40 to 49 years and those aged between 75 and 85 years with ?2 comorbid conditions, and biennial mammograms for women aged 50 to 75 years.

The investigators included in the total cost of mammography the cost of the procedure itself, recalls, biopsies, and computer-aided detection.

The data for the study came from the Behavioral Risk Factor Surveillance System (BRFSS) 2010 survey, conducted by the Centers for Disease Control and Prevention, to calculate the cost of the current screening approach in the United States. The investigators corrected for bias inherent in such telephone surveys, and excluded women aged 85 years, and women with a recent history of breast cancer.

In addition, the researchers used 2001 to 2007 data from the Breast Cancer Surveillance Consortium to calculate the percentage of women who would be recalled for repeated mammograms. They calculated the recall costs from the Digital Mammographic Imaging Screening Trial results of workup costs, and adjusted them for use of digital versus film mammography in 2010. They also adjusted all costs to 2010 US dollars.

They then estimated the number of women who would have undergone screening mammography in any given year—in this case 2010—based on previously reported frequency of mammography screening in the United States.

For example, 20% of women who are screened every 5 years were assumed to have had a screening mammogram, and 50% of those screened every 2 years were assumed to have done so in 2010. Based on the BRFSS data, it was estimated that 61% of women aged 40 to 75 years and 75% of women aged 65 to 70 years would have a screening mammogram in 2010 using their regular screening interval.

The investigators also determined that 85% of women would be compliant with biennial, annual, or USPSTF-based screening. Furthermore, for the simulated screening strategies of annual, biennial, and USPSTF guidelines, the researchers assumed that 85% of women would receive mammography screening.

For the estimate of screening costs using the USPSTF recommendations, the investigators assumed that 20% of women aged 40 to 50 years would be high-risk, and therefore would be screened once every 2 years. They also determined, based on Medicare reports, that approximately 50% to 75% of women aged 70 to 85 years have ?2 chronic conditions.

The team also found that besides screening frequency, the other largest contributors to cost were variation of the percentage of women screened, percent of film versus digital mammography, cost of individual mammograms, number of recalls, and cost of recalls.

Based on all these data, the total aggregate cost of actual mammography screening in 2010 was estimated to be approximately $7.8 billion. The total aggregate cost for annual screening would be $10.1 billion; by contrast, that cost would be $3.5 billion for screening based on the recent USPSTF recommendations, and $2.6 billion for biennial screening.

Better Use of Limited Resources?
In an accompanying editorial, Joann G. Elmore, MD, MPH, Professor, Department of Medicine, School of Medicine, and Adjunct Professor of Epidemiology, School of Public Health, University of Washington, Seattle, and Cary P. Gross, MD, Director, Cancer Outcomes, Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT, applaud the study (Elmore JG, Gross CP. Ann Intern Med. 2014; 160:203-204).

Dr Elmore and Dr Gross call for more consideration of cost in the conversations about optimizing breast cancer screening in the United States, from the individual physician–patient interaction to conversations among policymakers.

“It is unsustainable to remain ignorant of the costs associated with any health intervention, even breast cancer screening,” Dr Elmore and Dr Gross wrote.

“Following mammography screening guidelines, such as those from the USPSTF, that optimize frequency on the basis of best available evidence will put us in a position to improve screening and save billions of dollars that can be invested in personalized risk-based screening and prevention strategies,” Dr O’Donoghue and colleagues concluded.