Mammography cost varies by $8 billion annually, controversy ensues

The cost of mammography varies by at least $8 billion per year on the basis of screening strategy, according to a study published on Feb. 3 by the Annals of Internal Medicine.

Contention over the frequency and appropriate age to begin mammography screening for breast cancer detection is longstanding. Guidelines from the U.S. Preventive Services Task Force (USPSTF) and other major medical organizations have contrary recommendations for screening, leading to much debate and confusion amongst institutions, physicians and patients alike.

“Given the broad population that mammography serves, it is important to consider the economic effect of the conflicting guidelines,” wrote the study’s lead author, Cristina O’Donoghue, MD, MPH, of the University of Illinois at Chicago, and colleagues. The researchers aimed to inform the debate surrounding the cost-tradeoffs of the different recommendations by estimating the lower bound of the aggregate annual cost of mammography in the U.S. population for 2010 screening practices and guideline-recommended screening strategies.

Using a simulation model with a base case of mammography screening in 2010, the researchers simulated three strategies: annual, biennial and USPSTF from the payer perspective. The model’s final output was the aggregate cost of mammography screening per year for women ages 40 to 85 years old that included the costs of mammography, computer-aided detection and recalls and biopsies.

O’Donoghue and colleagues modeled participation rates from 61 percent of women between the ages of 40 and 45 years old to 75 percent of women between the ages of 65 and 70 years old, consequently estimating the aggregate cost of mammography screening in 2010 to be approximately $7.8 billion.

Annual screening of women between 40 and 84 years old cost an estimated $10.1 billion per year, in turn increasing mammography screening costs by $2.3 billion annually from actual practice. Biennial screening of women 50 to 70 years old is estimated to cost $2.6 billion each year and is the least expensive of the strategies. This number is $7.7 billion less than the annual screening estimation and $5.4 billion less than what’s estimated to be spent in actual practice.

The USPSTF strategy is a simulation of biennial screening for women 50 to 74 years old, as well as screening of high-risk women 40 to 49 years old and women 75 to 85 with less than three comorbid conditions. This strategy was estimated to cost $3.5 billion per year and $4.4 billion less than the actual price for 85 percent of the population.

“A screening policy following the USPSTF guidelines uses fewer resources, has fewer false-positive biopsy results and recalls compared with annual screening, and is being incorporated into quality guidelines,” wrote the authors. “Those who advocate annual screening should justify the increased costs of nearly $7 billion per year compared with biennial policies.”

O’Donoghue and colleagues suggest improving women’s health through the reallocation of resources and billions of dollars of savings from less-than effective mammography screening.

 “Such a change in screening practice is likely to improve the quality of screening and is in line with our national goals of advancing health care delivery while improving cost-efficiency,” they wrote.

Reactions to the study’s findings have been mixed so far. Joann G. Elmore, MD, MPH, of the University of Washington School of Medicine and School of Public Health in Seattle and Cary P. Gross, MD, of Yale School of Medicine in New Haven, Connecticut, wrote an associated editorial in the Annals of Internal Medicine on Feb. 3.

“Women and their providers do not know the costs associated with breast cancer screening, and national organizations have been hesitant to discuss this issue,” they wrote in their editorial, “The Cost of Breast Cancer Screening in the United States: A Picture Is Worth…a Billion Dollars?” “In this context, we applaud O’Donoghue and colleagues for meticulously assessing the total cost of breast cancer screening in the United States.”

Elmore and Gross also addressed the difficulty of incorporating cost into screening dialogues. “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 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 debate about which approach is most effective,” the authors wrote.

Though Elmore and Gross accepted and approved of the study’s findings, not all reactions were as positive. “The goal of health care is saving lives not dollars,” said the American College of Radiology (ACR) in a statement released on Feb. 3.

“The superficial financial analysis is flawed because it used only the cost of screening and did not include the costs associated with the failure to screen. The costs of morbidity, loss of income, treatment of metastatic disease, death and other real financial implications associated with a diagnosis of advanced breast cancer due to less frequent screening were not considered in their analysis,” wrote the ACR.

The statement concludes: “A national conversation regarding how to most efficiently use precious health care resources is welcome. However, this conversation should not be skewed by incomplete and misleading information. All involved should be aware of exactly what is being discussed, which, in this case, is letting thousands of women each year die unnecessarily from breast cancer.”