The complete understanding of the cost of breast cancer should include the cost of screening as well as that of treatment, according to researchers. There is a large body of evidence related to Medicare expenditures for the treatment of breast cancer, but little is known about the costs associated with screening for breast cancer in the Medicare population.
Because newer technologies for screening for breast cancer, including digital mammography and computer-aided detection, have given clinicians more options, the researchers commented that “it is particularly timely to consider the cost implications of breast cancer screening.” The new technologies can increase costs directly through reimbursement for the tests themselves as well as the possible increase in rates of supplementary imaging, biopsy, or cancer detection.
It is unclear, the researchers said, whether higher screening costs are associated with earlier stage at diagnosis or lower cancer treatment costs at the population level. To address these knowledge gaps, the researchers conducted a retrospective cohort study of female Medicare beneficiaries to assess breast cancer screening workups of suspicious lesions, and incident breast cancer. They reported study results in JAMA Internal Medicine [2013;173(3):220-226].
The researchers utilized the Surveillance, Epidemiology, and End Results-Medicare database to identify 137,274 women 66 to 100 years of age who were free of breast cancer as of December 31, 2005. The cohort was followed for 2 years. For the subgroup of women who developed breast cancer during the study period, the researchers estimated treatment cost during the initial 12 months following diagnosis.
The study also included an assessment of screening-related costs at the Hospital Referral Region (HRR) level and an evaluation of the association between regional expenditures and workup test utilization, cancer incidence, and treatment costs.
Of the total study cohort, 41.8% were <75 years of age (n=57,417), 83.8% were white (n=114,989), and half had ≥1 comorbid conditions (n=117,859). During the study period, 43.5% of the cohort had at least 1 screening mammogram; women 66 to 74 years of age were more likely to receive a mammogram than women 85 to 100 years of age (57.2% vs 15.2%), respectively (P<.001).
During the study period, the average annual breast screening-related cost per beneficiary was $63. There was, the analysis found, a strong inverse relation between age and cost, with breast cancer screening-related costs decreasing from $84 per beneficiary (for women 66-74 years of age) to $60 (75-84 years of age) to $21 (85-100 years of age), respectively (P<.001).
The mean cost of initial treatment per diagnosed patient was approximately $16,600 for all ages and $21,300, $12,800, and $11,500 for women diagnosed at ages 66 to 74 years, 75 to 84 years, and 85 to 100 years, respectively (P<.001).
Among the 75 HRRs, there was regional variation in screening-related cost per beneficiary. At the HRR level, the mean screening-related cost per beneficiary ranged from approximately $40 to $110; median cost was $64. There was a nearly 2-fold difference in cost per screened beneficiary between the highest and lowest HRRs (median HRR-level cost was $129).
Women residing in areas with higher screening-related cost per beneficiary were significantly more likely to be diagnosed as having breast cancer. This increase in breast cancer diagnoses was attributable to early-stage cancers; women in those areas tended to have a significantly higher incidence of in situ or stage I cancers.
In summary, the researchers said, “The cost to Medicare for breast cancer screening exceeds $1 billion annually in the fee-for-service program. Regional variation is substantial and driven by the use of newer and more expensive technologies; it is unclear whether higher screening expenditures are achieving better breast cancer outcomes.”