The cost of breast cancer screening in the Medicare population

Abstract

Background: Little is known about the cost to Medicare of breast cancer screening or whether regional-level screening expenditures are associated with cancer stage at diagnosis or treatment costs, particularly because newer breast cancer screening technologies, like digital mammography and computer-aided detection (CAD), have diffused into the care of older women.

Methods: Using the linked Surveillance, Epidemiology, and End Results-Medicare database, we identified 137 274 women ages 66 to 100 years who had not had breast cancer and assessed the cost to fee-for-service Medicare of breast cancer screening and workup during 2006 to 2007. For women who developed cancer, we calculated initial treatment cost. We then assessed screening-related cost at the Hospital Referral Region (HRR) level and evaluated the association between regional expenditures and workup test utilization, cancer incidence, and treatment costs.

Results: In the United States, the annual costs to fee-for-service Medicare for breast cancer screening-related procedures (comprising screening plus workup) and treatment expenditures were $1.08 billion and $1.36 billion, respectively. For women 75 years or older, annual screening-related expenditures exceeded $410 million. Age-standardized screening-related cost per beneficiary varied more than 2-fold across regions (from $42 to $107 per beneficiary); digital screening mammography and CAD accounted for 65% of the difference in screening-related cost between HRRs in the highest and lowest quartiles of cost. Women residing in HRRs with high screening costs were more likely to be diagnosed as having early-stage cancer (incidence rate ratio, 1.78 [95% CI, 1.40-2.26]). There was no significant difference in the cost of initial cancer treatment per beneficiary between the highest and lowest screening cost HRRs ($151 vs $115; P = .20).

Conclusions: The cost to Medicare of 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.

Figure 1

Regional variation in breast cancer screening costs

Figure 2

Figure 2A: Screening mammography and Computer Aided Detection use according to Health Referral Region screening-related cost Figure 2B: Work-up breast imaging and biopsy use according to Health Referral Region screening-related cost ^a CAD=Computer Aided Detection ^b Other Imaging Includes: Breast Ultrasound, Breast MRI, positron emitting tomography imaging; computed tomography of head, brain, thorax, abdomen; MRI of brain, brainstem; radiologic examination, consultation, report; three-dimensional rendering; bone and joint imaging; radiopharmaceutical localization of tumor ^c 1st quartile screening + work-up cost per beneficiary: <$57, 2nd quartile: $57–64, 3rd quartile: $65–70, 4th quartile: >$70

Figure 2

Figure 2A: Screening mammography and Computer Aided Detection use according to Health Referral Region screening-related cost Figure 2B: Work-up breast imaging and biopsy use according to Health Referral Region screening-related cost ^a CAD=Computer Aided Detection ^b Other Imaging Includes: Breast Ultrasound, Breast MRI, positron emitting tomography imaging; computed tomography of head, brain, thorax, abdomen; MRI of brain, brainstem; radiologic examination, consultation, report; three-dimensional rendering; bone and joint imaging; radiopharmaceutical localization of tumor ^c 1st quartile screening + work-up cost per beneficiary: <$57, 2nd quartile: $57–64, 3rd quartile: $65–70, 4th quartile: >$70