Screening Mammography: Costs & Benefits

Introduction:

The national cost of breast cancer care exceeds $20 billion a year, which is more than the cost of treatment for any other type of cancer (Ref. 1). In addition to the cost to the nation, the cost to the individual patient can be devastating. It is estimated that one in 4 families with breast cancer will be evicted from their homes because of bankruptcy due to medical costs (Ref. 2).

In large part, the acceleration of breast cancer cost is related to advances in medical care. Recent advances in chemotherapy can extend survival, but they are extremely expensive. Recent progress in immunotherapy can also be effective in extending the lives of patients with breast cancers, but the cost of immunotherapy can exceed $200,000 a year (Ref. 3-4).

Benefits of Early Detection

We are convinced that the most cost-effective strategy for controlling spiraling costs of breast care is to make the diagnosis of breast cancer before symptoms develop. When breast cancers are detected on a screening mammogram in asymptomatic women, the survival rate is 98% (Ref. 5). The life-time cost of care for asymptomatic patients is a small fraction of the cost of caring for women who have breast symptoms at the time the diagnosis is made. The lifetime cost of care for women who have breast symptoms, such as a lump or breast pain, can exceed $1 million.

We conclude that aggressive mammographic screening is the most effective strategy for improving breast cancer survival rates while at the same time lowering the lifetime cost of breast cancer care.

Summary Our Screening Guidelines

For more information, visit Our Optimal Screening Guidelines

• We recommend that women undergo risk assessment in their twenties. The assessment can be done by their primary care physician or can be performed at a risk-assessment clinic. Women who have a very strong family history of breast cancer should have screening at a risk assessment center as soon as she has developed breasts.
• We also recommend that all women have a Baseline 3D mammogram by age 35.
• Women who are determined to have a dense breast pattern are advised to have a yearly screening 3D mammogram.
• Women with non-dense breasts are given the option to defer yearly screening until reaching the age of 40.
• Women who have dense breasts and no major risk factors for developing breast cancer should have an additional yearly whole breast screening ultrasound.
• Women with a strong family history of breast cancer should have a yearly breast MRI in addition to their yearly screening mammogram.

Barriers to universal screening:

Costs

A national effort to promote universal breast cancer screening mammography will be costly. However, overtime, the cost of care will be reduced as more women are diagnosed with early- stage breast cancer and fewer women are diagnosed with more advanced cancer
(Ref. 6). The detection of early-stage breast cancer also reduces both the emotional and economic costs to the patients and their families.

Artificial Intelligence:

Artificial Intelligence (AI) can detect breast cancers that are not visualized on standard mammographic screening. One recent study found that AI assisted mammography could detect 79% of breast cancers that were not detected on standard mammographic screening (Ref. 7). When “machine learning” is applied to AI screening, the rates of early detection will continue to improve overtime (see article on Artificial Intelligence).

The reduction in the rates of unnecessary biopsies will markedly reduce the cost of screening as well as the emotional costs of having an unnecessary biopsy. (Ref. 8).

Motivation and Education

Recent studies have concluded that only 35% of insured women participated in yearly mammographic screening (Ref. 9). Rates of mammographic screening are even lower for women without health insurance. Free mammography is available to most women, but it is markedly underutilized (Ref. 10).

Motivation and education are also important factors in improving rates of mammographic screening. Sweden has years of experience in education and motivating women to undergo regular screening. Sweden has made a major commitment to bringing screening to women in rural communities by establishing mobile mammographic screening programs. A recent study concludes that 81% of women in Sweden participate in their national screening program (Ref. 11).

There is much to be learned from the Swedish experience. The first step to improving rates of screening in the USA is for the nation to commit to educating and motivating women to participate in yearly mammographic screening. In addition, the cost barriers to participate in yearly screening must be reduced.

One approach to improving rates of screening in underserved communities is to provide mobile mammography screening (Ref. 12). By making mammography more convenient, rates of participation increase. A second strategy to improving rates of screening is the use of Promotores in underserved Hispanic communities (Ref. 13). The Promotores typically are women raised in underserved Hispanic communities and have extensive training on the benefits of early detection. The Promotores go door to door in underserved communities to educate women on the value of screening for breast cancer. They can also schedule patients for mobile mammograms when they are available. Similar programs could be established in other underserved English-speaking communities. Underserved black communities are in urgent need of more aggressive screening (Ref. 14).

 

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