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

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 75 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
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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
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
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,
Current author addresses are available at
Ann Intern Med. 2014;160:203-204.
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JAMA. 2012;307:791-2. [PMID: 22357829]
3. 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.
4. Lee CI, Bassett LW, Lehman CD. Breast density legislation and opportunities
for patient-centered outcomes research. Radiology. 2012;264:632-6. [PMID:
5. Elmore JG, Fletcher SW. Overdiagnosis in breast cancer screening: time to
tackle an underappreciated harm [Editorial]. Ann Intern Med. 2012;156:536-7.
[PMID: 22473439]
6. National Cancer Institute. The Cost of Cancer. 2011. Accessed at www on 13 Decem-
ber 2013.
7. Bond M, Pavey T, Welch K, Cooper C, Garside R, Dean S, et al. Psycho-
logical consequences of false-positive screening mammograms in the UK. Evid
Based Med. 2013;18:54-61. [PMID: 22859786]
8. Patient-Centered Outcomes Research Institute. Patient-Centered Outcomes
Research Institute: Application Guidelines. 2012. Accessed at
/assets/PFAguidelines.pdf on 16 December 2013.
9. Fox J, Zikmund-Fisher BJ, Gross CP. Older patient experiences in the mam-
mography decision-making process [Letter]. Arch Intern Med. 2012;172:62-4.
[PMID: 22232149]
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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
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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 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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Background: Breast cancer is a global health problem that cannot be underestimated. Many studies have shown that breast cancer is related to pathogenic mutations in hereditary predisposition genes. Clinical practice guidelines play a vital role in guiding the selection of breast cancer screening. Little is known about the quality and consistency of guidelines' recommendations and their changes over these years. Methods: We reviewed the existing screening guidelines for genetic susceptibility to breast cancer and assessed the methodological quality, and summarized the recommendations to aid clinicians to make decisions. We conducted a systematic search in PubMed, Embase, Web of Science, and guideline-specific databases, aiming to find the guidelines of breast cancer due to hereditary predisposition. The necessary information was exacted by Excel. We also summarized different evidence grading systems. The qualities of the guidelines were assessed by the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument. Results: A total of 54 recommendations from 13 guidelines were extracted. Generally speaking, the recommendations were consistent, mainly focusing on mammography and MRI. Conclusions: The recommendations differ in details. Moreover, different guidelines are based on different grading systems, and some guidelines are not divided for age limits, which may limit the promotion and implementation of the guidelines. It is suggested that improvement can be made in this regard in the future.
... Data on the frequencies and costs of breast cancer diagnostic procedures are sparse, with many prior studies relying on Medicare records that pertain primarily to older segments of the affected populations and typically lower expenditure rates for procedures. 28,31 The risks and high costs of these diagnostic procedures point to unmet medical need, especially for technological advancements and quality initiatives that could minimize unnecessary invasive procedures, reduce costs, and optimize patient care for women during their breast diagnostic journey. ...
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Background Little data exist on real-world patterns and associated costs of downstream breast diagnostic procedures following an abnormal screening mammography or clinical exam. Objectives To analyze the utilization patterns in real-world clinical settings for breast imaging and diagnostic procedures, including the frequency and volume of patients and procedures, procedure sequencing, and associated health care expenditures. Materials and methods Using medical claims from 2011 to 2015 MarketScan Commercial and Medicare Databases, adult females with breast imaging/diagnostic procedures (diagnostic mammography, ultrasound, molecular breast imaging, tomosynthesis, magnetic resonance imaging, or biopsy) other than screening mammography were selected. Continuous health plan coverage without breast diagnostic procedures was required for ≥13 months before the first found breast diagnostic procedure (index event), with a 13-month post-index follow-up period. Key outcomes included diagnostic procedure volumes, sequences, and payments. Results reported descriptively were projected to provide US national patient and procedure volumes. Results The final sample of 875,526 patients was nationally projected to 12,394,432 patients annually receiving 8,732,909 diagnostic mammograms (53.3% of patients), 6,987,399 breast ultrasounds (42.4% of patients), and 1,585,856 biopsies (10.3% of patients). Following initial diagnostic procedures, 49.4% had second procedures, 20.1% followed with third procedures, and 10.0% had a fourth procedure. Mean (SD) costs for diagnostic mammograms of US$349 ($493), ultrasounds US$132 ($134), and biopsies US$1,938 ($2,343) contributed US$3.05 billion, US$0.92 billion, and US$3.07 billion, respectively, to annual diagnostic breast expenditures estimated at US$7.91 billion. Conclusion The volume and expense of additional breast diagnostic testing, estimated at US$7.91 billion annually, underscores the need for technological improvements in the breast diagnostic landscape.
... Furthermore, if the personal time expended by women being screened is valuable, then 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 receiving screening-related examinations. 15 Costs aside, screening also can lead to unintended consequences such as false sense of security, misdiagnosis and overdiagnosis. It is not uncommon for a woman discovering she has breast cancer to feel betrayed by years of normal mammograms. ...
... In the United States, mammography is estimated to account for almost $8 billion in annual health care expenditures. 89,90 Modeling estimates of screening mammography in the United States indicate that screening 85% of women would cost $10.1 billion with annual screening of women age 40 to 84 years (the American Cancer Society recommendation), $2.6 billion with biennial screening of women age 50 to 69 years (the European approach), and $3.5 billion with biennial screening for women age 50 to 74 years, personalized risk-based screening for women younger than age 50 years, and screening based on comorbid conditions for women age 75 years or older (US Preventive Services Task Force recommendations). 89 Other imaging modalities (eg, MRI) are more expensive than mammography, and they can result in greater recall for diagnostic evaluation. ...
Breast cancer screening is used to identify women with asymptomatic cancer with the goal of enabling women to undergo less invasive treatments that lead to better outcomes, ideally at earlier stages before the cancer progresses. There are important considerations for who should be screened, how often women should be screened, and with which imaging modality (or modalities). Ultimately, clinicians need to help women understand the benefits and risks of breast cancer screening in order to make informed decisions.
... Mammography practices differ from institution to institution, and subjective decisions about recalling women for follow-up imaging and diagnostic services after their initial mammogram vary widely, even among individual radiologists and diagnosticians working within particular institutions. 40,41 This analysis provides a range of results estimates to account for some of this variability. However, using a conservative estimate that one half of the approximately 39 million mammograms performed annually in the US are for screening (excluding Veterans Administration facilities), 42 then a crude extrapolation of our estimated per patient net cost savings of $28.53 suggests that use of DBT could account for over $550 million saved annually in US breast cancer health care spending if DBT were reimbursed at a rate of $50 more than FFDM. ...
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The objective of this study was to conduct a value analysis of digital breast tomosynthesis (DBT) for breast cancer screening among women enrolled in US commercial health insurance plans to assess the potential budget impact associated with the clinical benefits of DBT. An economic model was developed to estimate the system-wide financial impact of DBT as a breast cancer screening modality within a hypothetical US managed care plan with one million members. Two scenarios were considered for women in the health plan who undergo annual screening mammography, ie, full field digital mammography (FFDM) and combined FFDM + DBT. The model focused on two main drivers of DBT value, ie, the capacity for DBT to reduce the number of women recalled for additional follow-up imaging and diagnostic services and the capacity of DBT to facilitate earlier diagnosis of cancer at less invasive stages where treatment costs are lower. Model inputs were derived from published sources and from analyses of the Truven Health MarketScan(®) Research Databases (2010-2012). Comparative clinical and economic outcomes were simulated for one year following screening and compared on an incremental basis. Base-case analysis results show that 4,523 women in the hypothetical million member health plan who are screened using DBT avoid the use of follow-up services. The overall benefit of DBT was calculated at $78.53 per woman screened. Adjusting for a hypothetical $50 incremental cost of the DBT examination, this translates to $28.53 savings per woman screened, or $0.20 savings per member per month across the plan population and an overall cost savings to the plan of $2.4 million per year. The results of this study demonstrate clinical and economic favorability of DBT for breast cancer screening among commercially-insured US women. Wider adoption of DBT mammography presents an opportunity to deliver value-based care in the US health care system.
In order to shift US health care towards greater value, the Centers for Medicare & Medicaid Services (CMS) is exploring outpatient episode-based cost measures under the new Quality Payment Program and planning a bundled payment program that will introduce the first ever outpatient episodes of care. One novel approach to capitalize on this paradigm shift and extend bundled payment policies is to engage primary care physicians and specialists by bundling outpatient imaging studies and associated procedures—central tools in disease screening and diagnosis, but also tools that are expensive and susceptible to increasing health care costs and patient harm. For example, both breast and lung cancer screening represent target areas ripe for bundled payment given high associated costs and variation in management strategies and suboptimal care coordination between responsible clinicians. Benefits to imaging-based screening episodes include stronger alignment between providers (primary care physicians, radiologists, and other clinicians), reduction in unwarranted variation, creation of appropriateness standards, and ability to overcome barriers to cancer screening adherence. Implementation considerations include safeguarding against providers inappropriately withholding care as well as ensuring that accountability and financial risk are distributed appropriately among responsible clinicians.
In 2002, the German Federal Parliament decided that a quality-assured, population-based mammography screening program (MSP) should be introduced on the basis of the ‘European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis‘. The program was successively introduced between 2005 and 2009 and has been fully implemented since with country-wide coverage in more than 90 screening units. The overarching target of the MSP is a sustained reduction of breast cancer mortality. The current temporary approval according to the national X-ray ordinance is based on results from large randomised controlled mammography screening trials that were performed outside of Germany and more than 20 years ago. Up to date results on the benefit of the MSP in Germany are yet lacking. The Federal Office for Radiation Protection released on May 25, 2011 a call for proposals of a research project on the evaluation of the breast cancer mortality effects of the German mammography program. The research project is planned for a period of ten years and funded by the Federal Minister for Environment, Nature Conservation, Building and Nuclear Safety (BMUB), the Federal Ministry of Health (BMG) and the sponsors of the mammography cooperative (Kooperationsgemeinschaft Mammographie). The aim of this research project was to solidly analyse the impact of the German MSP on the breast cancer-specific mortality by employing several, mutually complementary and closely harmonized epidemiological observational studies. Given the complex organisational structure and data flow of the MSP, the German health and residents registration system and the constraints of the data privacy regulations, two feasibility studies were carried out prior to the scheduled main study.
Background: It is uncertain how changes in the U.S. Preventive Services Task Force breast cancer screening recommendations (from annual to biennial mammography screening in women aged 50-74 and grading the evidence as insufficient for screening in women aged 75 and older) have affected mammography use among Medicare beneficiaries. Materials and methods: Cohort study of 12 million Medicare fee-for-service women aged 65-74 and 75 and older to measure changes in 3-year screening use, 2007-2009 (before) and 2010-2012 (after), defined by two measures-proportion screened and frequency of screening by age, race/ethnicity, and hospital referral region. Results: Fewer women were screened, but with similar frequency after 2009 for both age groups (after vs. before: age 65-74: 60.1% vs. 60.8% screened, 2.1 vs. 2.1 mammograms per screened woman; age 75 and older: 31.7% vs. 33.6% screened, 1.9 vs. 1.9 mammograms per screened woman; all p < 0.05). Black women were the only subgroup with an increase in screening use, and for both age groups (after vs. before: age 65-74: 55.4% vs. 54.0% screened and 2.0 vs. 1.9 mammograms per screened woman; age 75 and older: 28.5% vs. 27.9% screened and 1.8 vs. 1.8 mammograms per screened woman; all p < 0.05). Regional change patterns in screening were more similar between age groups (Pearson correlation r = 0.781 for proportion screened; r = 0.840 for frequency of screening) than between black versus nonblack women (Pearson correlation r = 0.221 for proportion screened; r = 0.212 for frequency of screening). Conclusions: Changes in screening mammography use for Medicare women are not fully aligned with the 2009 recommendations.
Numerous clinical studies have confirmed that screening women age 40 years and older reduces breast cancer mortality by 30% to 50%. Several factors including faster breast cancer growth rates and lower breast cancer incidence among younger women, as well as shorter life expectancy and more comorbid conditions among older women, should also be considered in screening guidelines. Annual screening beginning at age 40 years and continuing with no upper age limit, as long as a woman has a life expectancy of at least 5 years and no significant comorbid conditions, is currently recommended.
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The timely convergence of advocacy efforts, high political will, and health care reform provides an important opportunity for the breast cancer community to help institute positive change in screening practices.
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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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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.
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.
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.
Aggregate cost of mammography screening in the United States: comparison of current practice and advocated guidelines
  • 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.