Cristina O'Donoghue

Aggregate Cost of Mammography Screening in the United States: Comparison of Current Practice and Advocated Guidelines

Context The total cost of alternative programs that screen for breast cancer is unknown. Contribution The actual cost of breast cancer screening in the United States in 2010 was

Evolving Paradigm for Imaging, Diagnosis, and Management of DCIS

7.8 billion. The cost would have been

Recognising the benefits and harms of breast cancer screening: an opportunity to target improvement

10.1 billion for screening every year,

Factors Associated with Preoperative Magnetic Resonance Imaging Use among Medicare Beneficiaries with Nonmetastatic Breast Cancer

2.6 billion for screening every 2 years, and

Breast MRI in the diagnostic and preoperative workup among medicare beneficiaries with breast cancer

3.5 billion for screening according to recommendations from the U.S. Preventive Services Task Force. Caution These results depend on assumptions, not all of which are equally well-supported. Implication Dollars saved under less expensive programs could be used to screen women who are not being screened. The Editors The frequency and appropriate age to start mammography screening for the detection of breast cancer have been debated in the United States for decades. Controversy intensified after the U.S. Preventive Services Task Force (USPSTF) recommended a change to biennial mammography on the basis that both annual and biennial screening reduce mortality rates, but biennial screening also decreases the negative effects (1). However, in the United States, there has been resistance to reducing frequency or modifying the age range for mammography. The USPSTF guidelines conflict with professional organizations, such as the American Cancer Society, which recommend annual screening from age 40 years and continued regardless of a womans age as long as she does not have serious, chronic health problems. Given the broad population that mammography serves, it is important to consider the economic effect of the conflicting guidelines. In 2009, the USPSTF recommended biennial screening for women between the ages of 50 and 74 years, with consideration of screening women aged 40 to 49 years on a riskbenefit decision (2). The USPSTF recommendations are based on a rigorous review of screening trials and work from the Cancer Intervention and Surveillance Modeling Network investigators that demonstrated that there is little net benefit in increasing the frequency of mammography (3). The Cancer Intervention and Surveillance Modeling Network modeling is corroborated by evidence from the Breast Cancer Surveillance Consortium, showing that false-positive recall and biopsy rates are significantly lower in the setting of biennial screening but without a significant increase in detected later-stage cancer (4, 5). The USPSTF recommendations on frequency are now in alignment with most European countries, where many of the defining mammography trials were conducted, with the exceptions of the United Kingdom and Finland, which screen every 3 years (611). Screening in the United States is delivered locally or regionally and covered by myriad payer and health plan organizations. Thus, the total resources required or the cost-tradeoffs of different recommendations are currently unknown. This study was designed to inform the debate by estimating the lower bound of the aggregate annual cost of mammography screening in the U.S. population when current (2010) screening practices are compared with guideline-recommended screening strategies. Our findings should be valuable to women, clinicians, and health policymakers alike who are aware of the many conflicting guidelines. Methods Study Design To estimate the cost of mammography in the United States, we created a simulation model using mammography screening in 2010 as our base case. We then simulated 3 strategies (annual, biennial, and USPSTF) from the payer perspective. Analyses were done using R (R Foundation for Statistical Computing, Vienna, Austria). Table 1 shows the 4 screening strategies, 1 of which is an estimate of actual practice (18, 19). The other 3 standardize on the population screened (85%) but differ on the age at which to start and stop and the frequency at which to screen. The biennial strategy represents the European approach, the annual strategy reflects the American Cancer Society (20) (among others) recommendations, and the USPSTF strategy (17) represents a risk-based strategy for screening those younger than 50 years and older than 75 years on the basis of their 2009 recommendations. Table 1. Model Inputs and Formulas The final output of the model was the aggregate cost of mammography screening per year. The summation included the costs of mammography, computer-aided detection (CAD), and recalls and biopsies. A description of the modeling methods is available in the Supplement. Supplement. Detailed Description of the Cost Models and the Sensitivity Analyses Inputs and Variables Model inputs were attained from several sources, including the Breast Cancer Surveillance Consortium (21), an observational data set designed to reflect mammography practice as it is done in the community and to reflect the distribution of women in the United States who have mammography, and they are listed in Table 1(13, 15, 16, 2224). All input variables except costs were age-specific. The number of mammography screenings was calculated by determining the population of women at risk by using census data. To focus on screening as opposed to diagnostic or surveillance mammography, we limited the population of women at risk to those between the ages of 40 and 85 years and excluded the number of women diagnosed with breast cancer in the past 5 years, who should be receiving surveillance mammography. We used data from the Behavioral Risk Factor Surveillance System 2010 Survey, a telephone health survey conducted by the Centers for Disease Control and Prevention, to determine the frequency and percentage of women receiving mammography. We corrected for survey bias by using the correction suggested by Rothman and colleagues (25). Although the survey does not distinguish between screening and diagnostic, we excluded women younger than 40 years and older than 85 years and those with recent history of breast cancer to best estimate screening as opposed to diagnostic mammography screenings (25). In our base-case model of actual practice, we included women who reported receiving mammography in the past 1 to 5 years and estimated the number who would have been screened in 1 given year; otherwise, the simulated strategies only simulated women receiving mammography every 1 or 2 years. The simulated strategies modeled a targeted participation of 85%, a screening participation achieved in the past for cervical cancer screening (26). For the USPSTF strategy, we modeled 20% of women aged 40 to 50 years as high-risk. We then simulated biennial screening for this cohort on the basis of evidence that women aged 40 to 49 years with a 2-fold increased risk have similar harmsbenefit ratios from biennial screening as women aged 50 to 74 years with average risk (27). The USPSTF strategy also modeled screening women between the ages of 70 and 85 years who are healthy, defined as having fewer than 3 self-reported chronic conditions as reported by Medicare (28). The percentage of recalled mammograms was obtained from the Breast Cancer Surveillance Consortium, using mammography screening performance data from 1908447 examinations for 749597 women screened from 2001 to 2007. Following the Breast ImagingReporting and Data System manual (29), a recall was defined as an initial Breast ImagingReporting and Data System assessment of 0 (needs additional imaging evaluation), 4 (suspicious abnormality), 5 (highly suggestive of malignancy), or 3 (probably benign finding) if it was accompanied by a recommendation for immediate work-up. Separate estimates were computed for recall rates at first and subsequent mammography screenings (that is, prevalent and incident screenings) as well as stratified by frequency of screening, digital versus film mammography, and a womans age. The estimated costs of the modeled strategies include the cost of screening mammography and the subsequent recall costs. Costs for mammography and CAD were determined using 2010 national Medicare reimbursements rates (16). Recall costs were calculated from the DMIST (Digital Mammographic Imaging Screening Trial) results of work-up costs, including additional imaging and biopsies from false-positive and true-positive examination results (24). We adjusted DMIST recall costs proportional to the use of digital versus film mammography in 2010. We adjusted all cost data to 2010 U.S. dollars on the basis of inflation as estimated by the medical portion of the Consumer Price Index (30). Sensitivity Analysis We used Monte Carlo simulations to estimate the uncertainty of our total cost estimates and quantify the sensitivity of the output (total cost) to the model inputs (Supplement) (31). In the sensitivity analysis, all terms in the formulas were assumed to be independent and follow -distributions as detailed in the Supplement. Role of the Funding Source This study was funded by the University of California and Safeway Foundation. The funding source had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript. Results Our model simulated screening practices in 2010 and estimated the aggregate U.S. population cost of mammography per year. Three mammography screening strategies advocated by various professional societies with targeted participation rates were also simulated and yielded costs that ranged from

Relationship between preoperative breast MRI and surgical treatment of non-metastatic breast cancer

10.1 billion for the most to

Locoregional treatment of breast cancer in women with and without preoperative magnetic resonance imaging

2.6 billion for the least intensive screening strategies (Figure 1). Figure 1. Comparison of the costs of screening strategies per year. Each bar represents the total cost of mammography screening per year, demarcating the costs from screening mammography and the subsequent recalls and biopsies. USPSTF = U.S. Preventive Services Task Force. The Aggregate Cost of Mammography Screening in the United States We estimated the aggregate cost of mammography screening in the United States by simulating screening for women aged 40 to 85 years, which follow a mixture of screening strategies in actual practice. Given the disparate recommendations and

Evaluation of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a community setting: A cost-utility analysis of a hospital's initial experience and reflections on the health care system

Our understanding of the biology of breast cancer has dramatically expanded over the past decade, revealing that breast cancer is a heterogeneous group of diseases. This new knowledge can generate insights to improve screening performance and the management of ductal carcinoma in situ. In this article, the authors review the current state of the science of breast cancer and tools that can be used to improve screening and risk assessment. They describe several opportunities to improve clinical screening: (1) radiologists interpreting mammograms should aim to differentiate between the risk for invasive cancer and ductal carcinoma in situ to better assess the time frame for disease progression and the need for and optimal timing of biopsy; (2) imaging features associated with low risk, slow-growing cancer versus high risk, fast-growing cancer should be better defined and taught; and (3) as we learn more about assessing an individuals risk for developing breast cancer, we should incorporate these factors into a strategy for personalized screening to maximize benefit and minimize harm.

Use of axillary lymph node dissection (ALND) in patients with micrometastatic breast cancer

Recognising the benefits and harms of breast cancer screening: an opportunity to target improvement

Aggregate Cost of Mammography Screening in the United States

Preoperative breast magnetic resonance imaging (MRI) use among Medicare beneficiaries with breast cancer has substantially increased from 2005 to 2009. We sought to identify factors associated with preoperative breast MRI use among women diagnosed with ductal carcinoma in situ (DCIS) or stage I–III invasive breast cancer (IBC). Using Surveillance, Epidemiology, and End Results and Medicare data from 2005 to 2009 we identified women ages 66 and older with DCIS or stage I–III IBC who underwent breast‐conserving surgery or mastectomy. We compared preoperative breast MRI use by patient, tumor and hospital characteristics stratified by DCIS and IBC using multivariable logistic regression. From 2005 to 2009, preoperative breast MRI use increased from 5.9% to 22.4% of women diagnosed with DCIS and 7.0% to 24.3% of women diagnosed with IBC. Preoperative breast MRI use was more common among women who were younger, married, lived in higher median income zip codes and had no comorbidities. Among women with IBC, those with lobular disease, smaller tumors (<1 cm) and those with estrogen receptor negative tumors were more likely to receive preoperative breast MRI. Women with DCIS were more likely to receive preoperative MRI if tumors were larger (>2 cm). The likelihood of receiving preoperative breast MRI is similar for women diagnosed with DCIS and IBC. Use of MRI is more common in women with IBC for tumors that are lobular and smaller while for DCIS MRI is used for evaluation of larger lesions.