Advances in Mammography Are Costing Medicare a Bundle

Megan Brooks

July 03, 2014

The amount of money Medicare spends on screening mammography has skyrocketed because of the increased uptake of newer screening methods, but this hasn't translated into earlier cancer detection, a new study shows.

In fact, the cost per person associated with breast cancer screening increased 47% from 2001 to 2009.

The study was published online July 1 in the Journal of the National Cancer Institute.

"We cannot simply adopt new technologies because they theoretically are superior — the health system cannot sustain it, and more importantly our patients deserve a sustained effort to determine which approaches to screening are effective and which ones are not," write Cary P. Gross, MD, director of the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at the Yale Cancer Center in New Haven, Connecticut, and colleagues.

Imaging modalities available for breast cancer screening have evolved substantially. In addition to technical advances in mammography, including digital image acquisition and computer-aided detection, the use of adjunct imaging modalities, such as breast ultrasound and MRI, has "diffused into clinical practice," the researchers report.

But the impact of these technologies on screening-related costs and outcomes is not clear, particularly in older women, they note.

Questionable Clinical Benefit

Dr. Gross and colleagues assessed the evolution of breast screening and costs from 2001 and 2009 using the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked database.

They identified 2 cohorts of women with no history of breast cancer. The 2001/02 cohort consisted of 137,150 women (mean age, 76 years) and the 2008/09 cohort consisted of 133,097 women (mean age, 77 years).

Rates of screening mammography in Medicare beneficiaries held steady over the study period, at round 42%. But the screening techniques changed.

The use of digital mammography rose from 2.0% in 2001/02 to 29.8% in 2008/09 (P < .001). And the use of computer-aided detection increased from 3.2% in 2001/02 to 33.1% in 2008/09 (P < .001).

Conversely, the use of film mammography decreased from 40.0% in 2001/02 to 12.9% in 2008/09 (P < .001).

In addition, a "considerable" number of women 75 years and older underwent screening mammography in 2001/02 (32.4%) and in 2008/09 (32.6%). The US Preventive Services Task Force does not recommend breast cancer screening for women 75 years and older.

"We were surprised to find that not only were about one third of women aged 75+ getting mammograms despite a lack of evidence to support this practice, but there was also a substantial increase in Medicare expenditures in this population," Dr. Gross told Medscape Medical News.

Costs Unsustainable

As a result of the increased use of more expensive mammographic techniques, the average screening-related costs per person increased from $76 to $112 over the study period (P < .001), and annual national fee-for-service Medicare spending increased from $666 million to $962 million, the researchers report.

Moreover, the increasing use of newer techniques did not lead to a statistically significant change in the detection rates of early-stage tumors from 2001/02 to 2008/09 (2.45 vs 2.57 per 1000 person-years; P = .41).

"Screening mammography is an important tool, but this rate of increase in cost is not sustainable," said study researcher Brigid Killelea, MD, from the Yale–New Haven Hospital, in a statement.

"We need to establish screening guidelines for older women that utilize technology appropriately, and minimize unnecessary biopsies and overdiagnosis to keep costs under control," she explained.

This study was not designed to assess the effectiveness of specific cancer screening technologies, Dr. Gross told Medscape Medical News. However, "our finding that there was a substantial increase in Medicare's investment in breast cancer screening, without a discernible improvement in screening outcomes, suggests that the Centers for Medicare & Medicaid Services should rigorously evaluate all new technologies before they are widely disseminated into clinical practice."

This study was supported by the National Cancer Institute and the Yale Cancer Center. Dr. Gross reports financial relationships with Medtronic, 21st Century Oncology, and FAIR Health. Some of his coauthors report financial relationships with industry, as detailed in the publication.

J Nat Cancer Inst. Published online July 1, 2014. Abstract

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