Patient undergoing mammography test in hospital.

A Yale-led study, which included researchers from the University of Oslo, and New York University, published in the March 23, 2020 edition of JAMA Internal Medicine found that there are substantial costs associated with breast cancer screenings for women in their 40s living in the United States. And while most private insurance companies reimburse the costs of mammography for women age 40 through 49 years, the study’s authors note that these costs vary widely by region.[1]

The study was supported by a grant from the American Cancer Society.

The researchers found that more than 40% of the eligible, privately insured women ages 40-49 received annual breast cancer screening in 2017. The estimated national cost of those procedures to be U.S. $ 2.13 billion per year. The authors of the study note that while many experts still debate the benefits of breast cancer screenings for women under age 50, there have only been a few studies related to associated costs of these procedures.

“These high costs underscore the importance of ramping up our research efforts to determine whether screening women in their 40s is beneficial or not,” noted senior author Cary Gross, M.D., Professor of Medicine and of Epidemiology and Founder and Director, Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, and a member of the Yale Cancer Center.

Breast cancer is the most common type of cancer impacting U.S. women and the fourth leading cause of cancer death in the United States.

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Photo 1.0: Cary Gross, MD is a Professor of Medicine and of Epidemiology. He is also the founder and director, Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine and Director, Adult Primary Care Center, Quality Improvement; Chair, National Clinician Scholars Program; Director, National Clinician Scholars Program.

“Because there is no consensus about the appropriate approach to breast cancer screening in this population, it is impossible to know how we should be investing our prevention dollars,” Gross added.

For this study, the researchers looked at the records from over 2 million women ages 40-49 from the Blue Cross Blue Shields Axis, a large commercial claims database accessed via a secure portal.  Of these women, 41.2% were screened with standard mammography, 24.1% with 2-dimensional mammography, and 17.2% with digital breast tomosynthesis (DBT) also known as 3-dimensional mammography.

In comparing these procedures, the researchers observed that costs varied substantially across different regions in the United States. They noted a mean cost of breast cancer screening to be  U.S. $ 353.00 per beneficiary, while screening costs ranged from U.S. $ 151.00 in some regions to U.S. $751.00 in others. Screening costs were highest in regions in California, New York, Alaska, Wisconsin, and Michigan. The lowest costs were seen in a number of regions in Alabama and Arkansas.

“We found substantial variation in the screening cost across U.S. regions,” said first author Natalia Kunst, a Yale research fellow and Ph.D. candidate at the University of Oslo.

“The identified costs were substantially higher than previously published cost estimates,” Kunst added.

While there is much debate about the risks and benefits of early breast cancer screening, most guidelines agree that average-risk women should receive mammography screening between ages 50 and 74 years.

A recent statement from the American College of Physicians noted that while clinicians should discuss screening with average-risk women patients ages 40 to 49, in most cases “the potential harms [of screening] outweigh the benefits.”

In contrast, the American Cancer Society’s recommends:

  • Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms (x-rays of the breast) if they wish to do so;
  • Women age 45 to 54 should get mammograms every year;
  • Women 55 and older should switch to mammograms every 2 years, or can continue yearly screening;
  • Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.

Cost considerations
The cost considerations identified by the authors of the study may provide a number of additional reasons to delay screenings.

“We hope that our results can assist local and national public health policymakers in making more informed choices about screening women ages 40 to 49 and identifying opportunities for research,” Kunst concluded.

[1] Kunst N, Long JB, Xu X, et al. Use and Costs of Breast Cancer Screening for Women in Their 40s in a US Population With Private Insurance. JAMA Intern Med. Published online March 23, 2020. doi:10.1001/jamainternmed.2020.0262 [Article]

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