Cost Effectiveness of Early Detection of Breast Cancer in Women at Average and Increased Risk

Scott Grosskreutz, M.D.

Screening mammography has been proven to be a cost effective method of reducing breast cancer deaths. According to the 2004 Institute of Medicine report entitled Saving Women’s Lives "Overall the evidence indicates that the availability of mammography to a community reduces mortality from breast cancer by 20-30%, and that in a population that actually participates in screening mammography, the reduction can be considerably greater, close to 50 percent" (1,2). Without screening mammography a long-term 50% cancer mortality rate can be expected (3,4). A similar death rate could be predicted to occur in those women who develop mammographically occult breast cancer, without the use of screening ultrasound. Mammography has been estimated to cost between $6,930.00 to $13, 413.00 per year of life expectancy gained, which is on a par with many other screening strategies in the U.S. (3)

The 2003 updated breast cancer guidelines of the American Cancer Society, recommend that women with an average risk of breast cancer be screened with mammography yearly starting at age 40. These ACS guideline recommend that women at high risk of breast cancer talk to their doctor about the risks and benefits of early initiation of screening, more frequent examinations or additional screening tests such as Ultrasound or MRI in additional to mammography. While a formal recommendation to screen all high risk women with additional tests does not yet exist, it’s important to note that this represents a major change in these national guidelines. A growing body of scientific research has shown that it is possible to find many more early stage cancers in women who are at high risk with mammographically dense breasts with ultrasound and MRI. Yearly mammograms alone may be insufficient to adequately screen BRCA carriers. The Hawaii Medical Association’s House of Delegates and the Hawaii State Legislature have unanimously passed resolutions stating that if women at high risk and their physicians agree on additional screening for breast cancer, that these additional tests should be made available to these women.

As with any screening protocol, additional tests for breast cancer in high-risk women must stand the test of cost effectiveness, especially in a time of rising health care costs. If a woman at high risk and her doctor agree on additional screening, then ultrasound should be considered. Ultrasound is readily available in most breast clinics. Ultrasound costs about the same as a mammogram, and is less expensive than MRI scans. The CPT code for a bilateral breast ultrasound is the same as a unilateral breast ultrasound, so imaging both breasts is no more expensive than imaging one breast. Several studies have shown that breast ultrasound in women at high risk with dense breasts with normal mammograms can at least double the number of early staged cancers that are found. Using ultrasound in addition to mammography in high risk women would double the cost of screening the small subgroup of high-risk women with dense breasts, estimated at 10-15% of women currently undergoing mammography. However, physicians would detect more than twice the number of curable cancers in these high-risk women, thereby reducing medical costs for society on treatment on the long run. According to the ACS guidelines prevalent screening studies with breast ultrasound, in women with mammographically normal dense breasts, have reported three to four breast cancers per thousand women in the general population. This ultrasound cancer detection rate is equal to mammography’s cancer detection rate in the general population (5, 6, 8, 9, 10, 11, and 12). The prevalence detection rate for high-risk women with ultrasound is significantly higher, ranging from 4.4 to 13 cancers per thousand women (5, 7, and 13). The use of yearly mammograms alone for women with BRCA mutations proved to be insufficient in one study, where nearly half the women developed malignant breast cancer less than a year after a normal mammogram (14).

The National Cancer Institute estimated that the total treatment expenditures for breast cancer in the US were six billion dollars in 1999. According to the American Journal of Managed Care, early detection is the key to reducing the cost of breast cancer because the cost per patient is higher for those who died, than for those who survived (15). Both the direct and indirect costs are dependent on the stage of breast cancer. The per patient costs for breast cancer in 1992 were estimated by the National Institute of Health to be $10, 813.00 for initial care, $1,084.00 per year for continuing care and $17,786.00 for terminal care (17). The currently estimated total direct and indirect cost for treatment of a patient with stage three breast cancers is $8,024.00, while the total cost of treatment of a stage four patient is substantially higher at $28,138.00 (16).

Conclusions:

Screening mammography for the general population has been shown to be cost effective.
The additional use of breast ultrasonography to screen the small subgroup of women at high risk of breast cancer with dense breasts would also be cost effective. Screening ultrasound for high-risk women is estimated to approximately cost the same amount of money per year of life saved as the use of mammography for the general population.
This analysis of the medical literature documents that finding breast cancers at a early curable stage saves both lives and decreases overall medical costs. Policies which fail to support the detection of early stage breast cancer, such as the trend to reimburse less than the costs of providing breast cancer screening services, will increase overall health care costs, as well as mortality rate of breast cancer.

Recommendations for average risk women:

Annual mammography beginning at age 40.

Recommendations for high-risk women:

Start mammography screening early. The ACS guidelines suggest age 30, although earlier screening might be clinically considered if there is a family history of early onset premenopausal breast cancer or positive oncogenes. If the breasts were largely of fatty density, then no other screening test would be indicated.
If the breasts are mammographically dense, then also consider annual screening ultrasound with mammography. In a highly motivated patient, or patients with BRCA mutations, suggest staggering the mammogram and the ultrasound at six-month intervals to better find rapidly growing neoplasms.
I would suggest reserving MRI for clinically problematic cases where the mammogram and ultrasound are felt to be inclusive and the radiologist recommends the study. The national practice guidelines of the American College of Radiology provide further guidance and indications for the use of breast MRI.

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