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The Cost of Breast Cancer Screening in the United States: A Picture Is Worth ... a Billion Dollars?

DOI:10.7326/M13-2943
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Joann G Elmore at University of Washington Seattle
Joann G Elmore
Cary Gross at Yale University
Cary Gross
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The Cost of Breast Cancer Screening in the United States: A Picture
Is Worth ...a Billion Dollars?
Breast cancer screening has been a charged issue for de-
cades. Concerns about access, quality, health promo-
tion strategies, and clinical effectiveness crescendo at vari-
ous times, but 1 factor is consistently overlooked: Cost.
Unlike purchases outside the health care arena, there are no
easily accessible price tags on screening mammography or
subsequent follow-up imaging tests and procedures. Health
care costs, in general, are usually obscured from view (1, 2).
The absence of readily available and reliable information
precludes valid assessments of costs at both the individual
patient and societal levels. Women and their providers do
not know the costs associated with breast cancer screening,
and national organizations have been hesitant to discuss
this issue.
In this context, we applaud O’Donoghue and col-
leagues (3) for meticulously assessing the total cost of
breast cancer screening in the United States. According to
the authors, we perform approximately 50 million screen-
ing mammography examinations per year at an annual cost
exceeding $7 billion. The authors use simulation models to
elucidate the U.S. population–level cost effect of 3 screen-
ing practices: screening women aged 50 to 69 years every
other year, following the U.S. Preventive Services Task
Force recommendations (personalized screening for
women in their 40s and aged ⱖ75 years and screening
every 2 years for women aged 50 to 74 years), and annual
screening for women aged 40 to 84 years. The authors
report that the annual cost of our U.S. breast cancer
screening program could vary from $2.6 billion for bien-
nial screening of women aged 50 to 69 years to $3.5 billion
for following the Task Force strategy and $10.1 billion for
annual screening starting at age 40 years.
Although there is often cause to be skeptical about
simulation models because results are based on numerous
assumptions, we find the article by O’Donoghue and col-
leagues to be reasonable and conservative. First, the authors
use Medicare reimbursement rates rather than the greater
costs associated with private payers. Second, the personal
time expended by women to receive mammography is
valuable and not considered in the accompanying models.
More than $1.5 billion can be added to annual screening
costs by applying the median U.S. hourly wage to an
estimated 2 hours allocated for traveling, waiting, and hav-
ing screening-related examinations. Third, the simulation
models do not consider the growing effect of newer and
more expensive screening and diagnostic technologies dis-
seminating into practice (magnetic resonance imaging, to-
mosynthesis, and molecular imaging). We will probably see
further increases in the use of these adjunctive technolo-
gies, in part because of state legislative activities directed at
increasing awareness and access to ultrasonography and
magnetic resonance imaging for women with increased
breast density (4).
The cost of treating overdiagnosed cases is another
important consideration. Some women who are diagnosed
with breast cancer during a screening examination may
have a type of cancer that is indolent and would not have
caused harm during their lifetime (5). It is impossible to
estimate the amount of treatment costs that can be attrib-
uted to overdiagnosis because the actual proportion of
breast cancer cases representing an overdiagnosis is uncer-
tain and contested. The overall expenses for treating breast
cancer were $16.5 billion in 2010 (6); anywhere from a
few hundred thousand dollars to $5 billion or more should
be added to the total annual cost of breast cancer screening.
Beneficial patient-centered issues, such as the reassur-
ance women feel after being screened, the early detection of
lesions that allows for more treatment options, and the
potential to save lives, are beyond the scope of the accom-
panying economic modeling study. However, they should
be considered. Other patient-centered issues that are not
taken into account are harms, such as the anxiety related to
false-positive results (7). Most women dread hearing, “An
abnormality was noted on your screening mammography
examination that might be breast cancer, and additional
testing is needed.”
The debate in the United States about the age at
which to start and frequency of mammography screening
stands in contrast to current practice in several European
nations. We suspect that most persons in the United States
are unaware that other countries do not begin breast cancer
screening programs until women are older than 50 years
and that most countries do not screen women annually.
For example, the national breast cancer screening program
in the United Kingdom invites women to be screened ev-
ery 3 years, beginning at age 50 years.
Integrating cost into the cancer screening conversation
is a challenge. Providers and patients are not only shielded
from cost information, but some may raise concerns that
the mere mention of costs is a step down the road to
rationing. However, both advocates and skeptics should
know the costs associated with different breast cancer
screening strategies, particularly when there is so much de-
bate about which approach is most effective. Further, clin-
ical guidelines frequently refrain from including cost in
their assessments and some research funders, such as the
Patient-Centered Outcomes Research Institute (PCORI),
do not include studies that focus on costs or cost-
effectiveness in their portfolio (8).
Although we all must take responsibility for the stew-
ardship of resources at the societal level, it is difficult to
grasp the concept of cost once in the range of billions
Annals of Internal Medicine Editorial
© 2014 American College of Physicians 203
Downloaded From: http://annals.org/ by a Universiy of Washington User on 12/19/2014
of dollars. The approximate $8 billion difference among
breast cancer screening strategies examined by the accom-
panying model is roughly twice as large as the entire annual
budget of the National Cancer Institute, the largest sup-
porter of research on all cancer (not just breast cancer) in
our country.
In the United States, our approach to optimizing
breast cancer screening needs to include education, because
the decision about screening lies with each woman. Unfor-
tunately, although physicians are comfortable discussing
the benefits of screening mammography, the potential
harms and issues of cost are less likely to be addressed
(9). This discussion is made more complicated by a lack
of consensus among professional organizations. Everyone
should become better educated about the potential bene-
fits, harms, and costs of breast cancer screening options
and the important role of patient age and breast cancer risk
in moderating the effectiveness of screening. Costs, includ-
ing out-of-pocket costs, should be part of the conversation
because women with high-deductible health plans may
find themselves facing a hefty bill for adjunctive imaging
tests and procedures. At the societal level, costs should be
integrated into our national dialogue about screening (10).
It is unsustainable to remain ignorant of the costs associ-
ated with any health intervention, even breast cancer
screening.
Joann G. Elmore, MD, MPH
University of Washington School of Medicine and School of
Public Health
Seattle, Washington
Cary P. Gross, MD
Cancer Outcomes Public Policy and Effectiveness Research
(COPPER) Center, Yale School of Medicine
New Haven, Connecticut
Potential Conflicts of Interest: Disclosures can be viewed at www
.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum
⫽M13-2943.
Requests for Single Reprints: Joann G. Elmore, MD, MPH, University
of Washington School of Medicine, 325 9th Street, Box 359780, Seattle,
WA 98104; e-mail, jelmore@uw.edu.
Current author addresses are available at www.annals.org.
Ann Intern Med. 2014;160:203-204.
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Editorial The Cost of Breast Cancer Screening in the United States
204 4 February 2014 Annals of Internal Medicine Volume 160 • Number 3 www.annals.org
Downloaded From: http://annals.org/ by a Universiy of Washington User on 12/19/2014
Current Author Addresses: Dr. Elmore: University of Washington
School of Medicine, 325 9th Street, Box 359780, Seattle, WA 98104.
Dr. Gross: Section of General Internal Medicine, PO Box 208093, Yale
School of Medicine, 333 Cedar Street, New Haven, CT 06520.
Annals of Internal Medicine
www.annals.org 4 February 2014 Annals of Internal Medicine Volume 160 • Number 3
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... 7 But breast cancer screening has been a controversial issue for decades. 8 In recent years, the prevalence of breast cancer has gradually increased, and the occurrence of breast cancer has been confirmed to be related to pathogenic mutations in hereditary predisposition genes. 9,10 One of the most crucial factors in the management of breast cancer is genetics. ...
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Objectives: To identify the psychological effects of false-positive screening mammograms in the UK. Methods: Systematic review of all controlled studies and qualitative studies of women with a false-positive screening mammogram. The control group participants had normal mammograms. All psychological outcomes including returning for routine screening were permitted. All studies had a narrative synthesis. Results: The searches returned seven includable studies (7/4423). Heterogeneity was such that meta-analysis was not possible. Studies using disease-specific measures found that, compared to normal results, there could be enduring psychological distress that lasted up to 3 years; the level of distress was related to the degree of invasiveness of the assessment. At 3 years the relative risks were, further mammography, 1.28 (95% CI 0.82 to 2.00), fine needle aspiration 1.80 (95% CI 1.17 to 2.77), biopsy 2.07 (95% CI 1.22 to 3.52) and early recall 1.82 (95% CI 1.22 to 2.72). Studies that used generic measures of anxiety and depression found no such impact up to 3 months after screening. Evidence suggests that women with false-positive mammograms have an increased likelihood of failing to reattend for routine screening, relative risk 0.97 (95% CI 0.96 to 0.98) compared with women with normal mammograms. Conclusions: Having a false-positive screening mammogram can cause breast cancer-specific distress for up to 3 years. The degree of distress is related to the invasiveness of the assessment. Women with false-positive mammograms are less likely to return for routine assessment than those with normal ones.
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Older Patient Experiences in the Mammography Decision-Making Process
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Full-text available
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In conclusion, the VA has increased its HIV testing from 2009 to 2010; however, there is still room for improvement. It is current VA policy that every veteran be offered HIV testing at least once in a lifetime, regardless of risk factors and age, and that all veterans identified as HIV positive be linked to high-quality comprehensive care in a timely manner. The VA's OPH will continue to collect annual HIV testing data and strive to improve HIV testing rates throughout the entire VA system.
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Aggregate Cost of Mammography Screening in the United States: Comparison of Current Practice and Advocated Guidelines
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Controversy exists over how often and at what age mammography screening should be implemented. Given that evidence supports less frequent screening, the cost differences among advocated screening policies should be better understood. To estimate the aggregate cost of mammography screening in the United States in 2010 and compare the costs of policy recommendations by professional organizations. A model was developed to estimate the cost of mammography screening in 2010 and 3 screening strategies: annual (ages 40 to 84 years), biennial (ages 50 to 69 years), and U.S. Preventive Services Task Force (USPSTF) guidelines (biennial for those aged 50 to 74 years and personalized based on risk for those younger than 50 years and based on comorbid conditions for those 75 years and older). United States. Women aged 40 to 85 years. Mammography annually, biennially, or following USPSTF guidelines. Cost of screening per year, using Medicare reimbursements. The estimated cost of mammography screening in the United States in 2010 was $7.8 billion, with approximately 70% of women screened. The simulated cost of screening 85% of women was $10.1 billion, $2.6 billion, and $3.5 billion for annual, biennial, and USPSTF guidelines, respectively. The largest drivers of cost (in order) were screening frequency, percentage of women screened, cost of mammography, percentage of women screened with digital mammography, and percentage of mammography recalls. Cost estimates and assumptions used in the model were conservative. The cost of mammography varies by at least $8 billion per year on the basis of screening strategy. The USPSTF guidelines are based on the scientific evidence to date to maximize patient benefit and minimize harm but also result in far more effective use of resources. University of California and the Safeway Foundation.
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The Cost of Breast Cancer Screening in the Medicare Population
Article
  • Jan 2013
Background: Little is known about the cost to Medicare of breast cancer screening or whether regional-level screening expenditures are associated with cancer stage at diagnosis or treatment costs, particularly because newer breast cancer screening technologies, like digital mammography and computer-aided detection (CAD), have diffused into the care of older women. Methods: Using the linked Surveillance, Epidemiology, and End Results-Medicare database, we identified 137 274 women ages 66 to 100 years who had not had breast cancer and assessed the cost to fee-for-service Medicare of breast cancer screening and workup during 2006 to 2007. For women who developed cancer, we calculated initial treatment cost. We then assessed screening-related cost at the Hospital Referral Region (HRR) level and evaluated the association between regional expenditures and workup test utilization, cancer incidence, and treatment costs. Results: In the United States, the annual costs to fee-for-service Medicare for breast cancer screening-related procedures (comprising screening plus workup) and treatment expenditures were $1.08 billion and $1.36 billion, respectively. For women 75 years or older, annual screening-related expenditures exceeded $410 million. Age-standardized screening-related cost per beneficiary varied more than 2-fold across regions (from $42 to $107 per beneficiary); digital screening mammography and CAD accounted for 65% of the difference in screening-related cost between HRRs in the highest and lowest quartiles of cost. Women residing in HRRs with high screening costs were more likely to be diagnosed as having early-stage cancer (incidence rate ratio, 1.78 [95% CI, 1.40-2.26]). There was no significant difference in the cost of initial cancer treatment per beneficiary between the highest and lowest screening cost HRRs ($151 vs $115; P = .20). Conclusions: The cost to Medicare of breast cancer screening exceeds $1 billion annually in the fee-for-service program. Regional variation is substantial and driven by the use of newer and more expensive technologies; it is unclear whether higher screening expenditures are achieving better breast cancer outcomes.
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Aggregate cost of mammography screening in the United States: comparison of current practice and advocated guidelines
  • Jan 2014
  • ANN INTERN MED
  • 145-53
  • O 'donoghue
  • C Eklund
  • M Ozanne
  • E M Esserman
O'Donoghue C, Eklund M, Ozanne EM, Esserman LJ. Aggregate cost of mammography screening in the United States: comparison of current practice and advocated guidelines. Ann Intern Med. 2014;160:145-53.