Medicare spending on breast cancer screening increased substantially between 2001 and 2009 but the detection rates of early stage tumors were unchanged, according to a new study published July 16 in the JNCI: Journal of the National Cancer Institute.
The effect of introduction of new breast cancer screening modalities, such as digital images, computer-aided detection (CAD), and use of ultrasound and MRI on screening costs among older women is unknown, although women over the age of 65 represent almost one-third of the total women screened in the US annually. There is conflicting evidence regarding benefit of screening for older women and newer modalities have not been in use long enough to establish a relationship between these new modalities and breast cancer mortality.
Brigid K. Killelea, M.D. M.P.H., from Department of Surgery and Cary P. Gross, M.D., of the Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center at the Yale Cancer Center and Yale University School of Medicine, New Haven, CT, and colleagues investigated changes in breast cancer screening and associated costs among elderly women in the US and analyzed changes in cancer stage and incidence rates. Using data from the SEER-Medicare linked database, they created two cohorts of women: a cohort of 137,150 women screened between 2001 and 2002 (before the introduction of new screening modalities), and a cohort of 133,097 women screened between 2008 and 2009 (after the introduction of new screening modalities).
They observed that while overall screening rates remained stable, the use of digital image acquisition and CAD increased. At the national level, there was a substantial increase in screening-related costs in the Medicare program ($666 million to $962 million), although a statistically significant change in detection rates of early stage tumors was not observed.
The authors conclude, "Longer follow-up data with regard to stage-specific incidence, cost, and patient reported experiences relating to both screening and treatment are needed in order to inform decisions about screening Medicare beneficiaries for breast cancer."
In an accompanying editorial, Karla Kerlikowske, M.D. (Department of Epidemiology and Biostatistics, and the General Internal Medicine Section, Department of Veterans Affairs, both at the University of California, San Francisco, CA), Rebecca Hubbard, Ph.D., (Group Health Research Institute, Group Health Cooperative, Seattle, WA), and Anna N.A. Tosteson, Sc.D., (The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH), discuss how the study by Killelea et al. adds to the literature reporting higher costs for digital mammography among older women without a clear added benefit to women. They write, "the transition to digital breast cancer screening in the U.S. has increased screening mammography costs for possibly small or no health gains resulting in screening mammography being less cost-efficient than in the past."
- B. K. Killelea, J. B. Long, A. B. Chagpar, X. Ma, R. Wang, J. S. Ross, C. P. Gross. Evolution of Breast Cancer Screening in the Medicare Population: Clinical and Economic Implications. JNCI Journal of the National Cancer Institute, 2014; 106 (8): dju159 DOI: 10.1093/jnci/dju159
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