Medicare-funded breast cancer screenings jumped 44 percent from $666 million to $962 million from 2001 to 2009, yet those added costs did not improve early detection rates among the 65 and older Medicare population, according to a Yale School of Medicine study published recently in the Journal of the National Cancer Institute.
The increase was due mostly to the use of costlier digital mammography ($115 per screening) compared to film mammography ($73 per screening), along with newer and expensive screening and adjunct technologies, including breast ultrasound, magnetic resonance imaging (MRI) and biopsy. The study is the second from Yale since January 2013 to conclude that increased Medicare spending for breast cancer screening does not necessarily translate into better outcomes.
The latest study has spurred debate about the cost and value of mammography in Medicare beneficiaries, particularly women 75 and older. Some physicians recommend continued screening, while others argue that it is unnecessary and only fuels anxiety among older women.
And with Medicare beneficiaries comprising one-third of the 37 million American women screened each year, the cost implications of breast-screening procedures on the Medicare budget are significant, researchers said.
“Clinicians and patients need to start thinking about the bang they are getting for their buck,” said Dr. Anees Chagpar, director of the Breast Center – Smilow Cancer Hospital at Yale-New Haven, and a co-author of the study. “We must be cognizant of our use of technology and healthcare dollars.”
“Our country and health system have finally recognized that this aggressive and dramatic rise in health care costs is not sustainable,” said Dr. Cary Gross, director of the Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale Cancer Center and one of the study’s lead authors. “We need to make choices about how to prioritize our healthcare spending.”
But some breast cancer experts worry that older women who are healthy will misinterpret the Yale findings to mean they don’t need an annual mammogram.
Dr. David Gruen, director of Women’s Imaging and co-director of the Breast Center at Stamford Hospital, called the recent Yale study “much ado about nothing.”
“Women should get an annual mammogram as long as they are healthy, and age should not be the discriminator,” said Gruen. “Breast cancer is the enemy. We should not politicize things (such as screening mammography) that have been shown to save lives.”
Dr. Liane Philpotts, chief of Breast Imaging at Yale- New Haven Hospital, called the study’s hypothesis that more advanced imaging would lead to improved cancer detection rates “absolutely unfounded.” She cited a 2005 clinical trial of digital versus film mammography that showed no difference in detecting cancer in the general population of women, except for women with dense breast tissue.
“Unfortunately, this study makes mammography look bad,” said Philpotts, who is a professor of diagnostic radiology at the Yale School of Medicine.
Dr. Jean Weigert, director of Breast Imaging at the Hospital of Central Connecticut and president of the Radiological Society of Connecticut, said the study’s focus on a two-year period was probably too brief to measure the incidence of breast cancer. Yale researchers acknowledge the need for future studies with longer follow-up periods.
Rapid Technological Changes
The Yale study looked at 270,247 women aged 66 years and older with no history of breast cancer during separate two-year periods (2001 – 2002 and 2008 – 2009). Researchers chose this period because it marked the rapid adoption of digital mammography and computer aided detection into clinical settings.
Among the findings:
• The average cost per person for all screening-related tests (including screening and work-up procedures) increased by 47.4 percent from $76 to $112.
• The cost of adjunct testing, including imaging and biopsy, increased 34 percent from $32 to $43 per beneficiary.
• The use of digital imaging for screening mammography increased from 2 percent to 29.8 percent. Computer-aided technology with mammography rose from 3.2 percent to 33.1 percent.
• Despite the additional costs, cancer detection rates did not change over the study period. The number of women screened remained stable at around 42 percent.
Yale researchers emphasize they aren’t calling for a return to film mammography, especially since 95 percent of the nation’s mammogram machines are digital.
“Digital mammography is a good thing,” said Chagpar.
Hospitals and imaging centers in Connecticut use digital mammography machines that provide clearer, more detailed images that are easier to store, share and enhance than film mammograms. Studies show digital mammography is more accurate at detecting cancer in women with denser breasts. Radiologists use computer-aided detection software to spot abnormalities that might otherwise go undetected.
But advanced imaging technology can lead to additional imaging studies or biopsies that add to the total cost of mammographic screening, researchers said. Adjunct tests are useful in high-risk populations, such as breast MRI for women with gene mutations and screening breast ultrasound for women with dense tissue. Technology, however, can be over-used in women at low or average risk for breast cancer.
“We need to personalize our recommendations so we use the right test in the right population for the right reason to get the right outcome,” said Chagpar, “rather than using a cookbook, one-size-fits-all approach that simply increases cost without increasing value.”
Mammography In Older Women
The value of annual mammograms for older women has been controversial for some time because no conclusive evidence exists, experts said.
The U.S. Preventive Services Task Force does not recommend breast cancer screening for women age 75 years and older. But the Yale study found Medicare still spent an increasing amount per woman 75 years and older, with costs rising 43 percent from $58 to $83. About a third of women 75 and older received screening mammography.
“Some older women are unnecessarily having costly breast cancer screenings and adjunct procedures that only increase anxiety among patients,” said Gross. These include women with a limited life expectancy or complicating factors that preclude cancer treatment.
“Reflexively ordering mammograms every year is probably not the right thing to do, not just in terms of finances, but also in terms of what you are subjecting patients to,” said Dr. Kimberly Caprio, medical co-director of the Comprehensive Women’s Health Center at St. Francis Hospital and Medical Center.
Instead, women and physicians should consider a combination of factors – age, breast cancer risk, life expectancy and overall health status – when weighing the risk and benefits of annual mammography.
“There are many women 75 years and older who are still healthy, active and working,” said Weigert. “Getting a breast cancer that was not diagnosed as early as possible would really affect their morbidity and mortality.”
At 77, Nora K. Fox of Avon has been getting yearly mammograms for nearly four decades and she has no plans to stop. Fox was diagnosed with breast cancer four years ago following a mammogram. She underwent a lumpectomy and radiation therapy, and now takes a daily dose of anastrozole.
“I feel terrific,” said Fox, who has a family history of breast cancer. “I walk a couple of miles a day and still play golf. I have six grandkids that I’m watching grow up.”
She’s read the literature about slow-growing cancers being less of a concern for older women. “But I’m not willing to take that chance,” said the retired teacher. “I don’t know what would have happened if I hadn’t had a mammogram at age 73.”
The 3D Future
The debate over cost and technology has now shifted to three-dimensional (3D) mammography, the latest innovation used in conjunction with a traditional digital mammogram. Some experts believe 3D mammography remains “investigational” and more studies are needed to determine its efficacy.
Others claim the evidence already exists, citing an August study in the Journal of the American Medical Association that found 3D mammography associated with a decrease in the number of women called back for more testing and increased cancer detection.
At Stamford Hospital’s Breast Center, for example, all patients undergo 3D mammography because “we find more breast cancers and we call back fewer patients,” said Gruen.
“It’s a no-brainer.”
Dr. Kristen Zarfos, the director of the Comprehensive Breast Health Program at The Hospital of Central Connecticut, division of the Hartford HealthCare Cancer Institute, will answer your questions on mammography and other breast cancer topics during a live chat on courant.com, Wednesday, from 12:30-1 p.m. This live chat is a collaboration between the Hartford Courant and C-HIT. To sign up go to www.courant.com/beyondpink