Breast Cancer Screening Costs Driven by High-Tech Approaches

Medicare costs of screening for breast cancer exceeded $1 billion during 2006 to 2007, according to results from a new study, with those costs substantially linked to regional variations in the use of new, expensive screening technologies.

Still, it remains unclear whether high-tech screening tools improve outcomes, according to the authors of the study.

Writing in an article published online January 7 in JAMA Internal Medicine (formerly Archives of Internal Medicine), lead author Cary Gross, MD, from Yale University's Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut, and colleagues point out that although new screening technologies, such as digital mammography and computer-aided detection, provide more options for screening, they can also drive up Medicare costs in at least 2 ways: first, through Medicare's direct reimbursement for the tests; and second, through the results of the tests possibly triggering the need for more imaging tests, biopsies, and detection of cancers.

"It is critical," the authors write, "to assess the relation between screening expenditures and population outcomes since newer modalities can increase cancer detection rates but may not improve patient outcomes, particularly among older women."

To look into that issue more closely, these investigators used the linked Surveillance, Epidemiology, and End Results–Medicare database to identify 137,274 women between 66 and 100 years of age who had not previously been diagnosed with breast cancer. Then they tallied Medicare's costs during the 2-year period from 2006 to 2007 for fee-for-service breast cancer screening in that cohort of women.

In addition, they assessed Hospital Referral Region (HRR) data to compare regional variations in breast cancer screening costs and assessed the associations among regional screening costs, the incidence of cancer cases, and the costs of treating them.

$1 Billion Annually

The authors report that Medicare's fee-for-service program spent more than a billion dollars annually during the 2 years studied. "This accounted for over 45% of the $2.42 billion total spent by Medicare on screening and the initial treatment phases of breast cancer, suggesting that analyses that focus exclusively on treatment have overlooked a significant contributor to cancer costs," they write.

The authors also found that for women aged 75 years and older, annual costs for screening-related procedures were $410.6 million.

Regional costs of screening varied considerably between geographic areas, in some cases by more than 2-fold ($42 - $107 per beneficiary). The authors say that 2 screening modalities (digital screening mammography and computer-aided detection) accounted for 65% of screening-related costs between HRRs.

The authors further report that women who resided in HRRs with high screening costs were more likely to be diagnosed with early-stage cancers than were their cohorts living in areas where screening costs were lower (incidence rate ratio, 1.78; 95% confidence interval, 1.40 - 2.26).

Even so, the authors write, "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)."

The authors conclude that costs of treating breast cancer in Medicare patients, when screening costs are figured in, are substantially higher than has previously been documented. In addition, they say, those costs may go up more steeply than projected, "owing to Medicare's reimbursement strategy, which supports rapid adoption of newer modalities, frequently without adequate data to support their use."

In an invited commentary, Jeanne Mandelblatt, MD, MPH, from Georgetown University, Washington, DC, and colleagues characterize the findings of the Gross study as "compelling." However, they say the findings do not fully answer the question of whether investing in new, more expensive digital screening technology improves breast cancer outcomes for older women.

They say that definitive randomized clinical trials specific to older populations are needed to help sort out such questions.

The commentators conclude, "For all these conditions, interventions, and decisions about Medicare coverage, the real question raised by the research of Gross et al that must be answered is how we put a value on the life of any person or group."

This study was supported by the National Cancer Institute and the P30 Cancer Center Support Grant at the Yale Comprehensive Cancer Center. One coauthor is supported by the National Institute on Aging and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program, by the Centers of Medicare and Medicaid Services, and by the Pew Charitable Trusts. The collection of the California cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the National Cancer Institute's SEER Program, and the Centers for Disease Control and Prevention's National Program of Cancer Registries. Drs. Gross and one coauthor are members of a scientific advisory board for FAIR Health Inc and receive support from Medtronic Inc to develop and implement methods of clinical trial data sharing and patient-level meta-analyses. Another coauthor has received research funding from and has served as a consultant for Abraxis Oncology (currently Celgene), Merck, Novartis, Glaxo-Smith-Kline, and Genentech/Roche. The other authors have disclosed no relevant financial relationships. The editorialists are supported by the National Cancer Institute and the National Institutes of Health.

JAMA Intern Med. Published online January 7, 2013. Abstract