Abnormal mammogram. These studies are often difficult to interpret. Internet photo
According to the AP (4/7, Alonso-Zaldivar), “a new report estimates that the U.S. spends $4 billion a year on unnecessary medical costs due to mammograms that generate false alarms, and on treatment of certain breast tumors unlikely to cause problems.” The research, published in “Health Affairs, breaks the cost down as follows: $2.8 billion resulting from false-positive mammograms and another $1.2 billion attributed to breast cancer overdiagnosis,” which is “the treatment of tumors that grow slowly or not at all, and are unlikely to develop into life-threatening disease during a woman’s lifetime.”
CNBC (4/7) reports that “those costs are so high that they ‘may tilt the balance to the point where screening appears relatively cost-ineffective,’ the authors wrote in the conclusion of the report, which looked at expenditure data from more than 702,000 women with health insurance.”
On its website, NBC News (4/7, Fox) reports on the study, and also reports that a second study published in Health Affairs “shows that new treatments for women who really do have breast cancer may cost more, but they are helping them survive longer than older treatments.”
The New Haven (CT) Register (4/7) reports that investigators “compared breast cancer survival rates and treatment costs in two time periods, 1994-96 and 2004-06, analyzing Medicare billing records of 9,708 women between 67 and 94 years old.”
HealthDay (4/7, Dallas) reports that the researchers found “that the costs for treating women with stage 3 breast cancer jumped from $18,100 to roughly $32,600.” The data also indicated that “the five-year survival rate for these women improved from 38.5 percent to 52 percent.”
Blogfinger Medical Commentary: Paul Goldfinger, MD, FACC
There are a few points to be made regarding the latest cost information about mammograms:
1. Over diagnosis occurs when mammograms are read suggesting cancer when there is none. That is called a “false positive” and it happens in about 11% of studies, especially in patients 40-49 years old, a group where some experts say that screening is not necessary. But it is not only a question of increased dollar costs. False positives also cost more in terms of psychological stress and/or biopsies. But false positives do not equate with poor medicine. It has to do with mammography limitations; it is an imperfect test, and radiologists who specialize in reading those tests do everything possible to try for accurate interpretations.
Radiologists ask for more X-rays in a high percent of cases, because they see something which they think is suspicious, but more films resulti in extra radiation accumulating each time a mammogram is done.
2. Cost analysis in over 700,000 women says that billions of dollars are wasted as a result of “unnecessary medical costs due to mammograms.” But that doesn’t negate the value of mammography in screening. Most medical screening tests are not totally accurate, as with the PSA with men. Research to improve diagnostic accuracy is ongoing, and there is the potential to save money and suffering.
3. As for therapy, the costs of effective breast cancer treatments are rising, largely due to radiation and chemotherapy, but more lives are being saved with stage II and III disease, so the increased cost has to be accepted; but wasteful spending for treatments should be identified and that will reduce expenses for the system.
4. These issues need further sorting out. Meanwhile many women do not obtain mammograms for a variety of reasons. Doctors will be able to identify those who are at highest risk for fatal breast cancer, and risk assessment can help target those who especially need the test and in whom mammography has a higher chance of saving lives. This involves risk factor screening such as for smoking, poverty, family history, race and obesity. Genetic screening will also add to the effectiveness of sorting out risk.
5. Public health efforts to increase awareness of screening are important, but they require more than just hanging pink ribbons and banners. Volunteers need to go into communities and talk to women, especially in the poorer and more vulnerable populations.
Jason. Your case report is lacking in precise facts, and some of your statements are out of line. I will not comment on that patient, but I would like to make a few general points:
1. No doctor would use terminology such as “weakly positive.” Radiologists do not make the diagnosis of cancer. That can only be made by a pathologist examining tissue. Doctors who read mammograms look for normal radiologic findings or for a wide spectrum of suspicious changes. If they see anything suspicious they always react, and they usually do not wait for 6-9 months to perform an earlier than usual followup.
Typically they order more X-rays, often by obtaining additional views or by supplementing the mammogram with ultrasound imaging or even MRI. If necessary biopsies will be done. If they have old films, they will compare to see if progression has occurred.
Radiologists are obsessive about accurate diagnosis, so they pursue that with great vigor. The test can miss small cancers, but the doctors will do whatever they can to avoid a miss. As a result, sometimes their suspicious findings turn out to be harmless. That is a “false positive” but that is not bad medicine.
The study presented is about the rising cost of care, but it is not wasted money unless somebody is doing unwarranted testing. Saying that costs are going up is not judgmental per se.
Certainly there are controversies about the use of mammography for cancer screening, but the experts will iron out those issues with the best interest of patient care in mind, and nothing else!
In the case of breast cancer, more accurate testing technology and more clinical trials will make screening better.
And if you are right that politicians or “bean counters” might interfere, then physicians should and will complain to follow their sworn promise to put the best interest of patients first above all else.
Better safe than sorry. I had an ~40 year old employee who worked for me who died from breast cancer 4 years ago. She told me after her diagnosis of breast cancer, which had entered the lymph nodes, that she had a mammogram every year and the year before she got sick with cancer, the doctor told her there was a weakly positive observation. He counseled her that it was likely a false positive and that she should come back in 6-9 months for a repeat. He put forth the party line that a biopsy would be expensive and unpleasant and probably was unnecessary. He did leave the final choice to her but nonetheless, her husband ultimately successfully sued the doctor (money given to her college for a scholarship fund). Unfortunately, his wife was dead.
Moral of the story: whether it be breast, prostate, or whatever kind of cancer, don’t role the dice. Go to any length necessary to assure you protect yourself. Don’t let bean counter, government types gamble with your life. Don’t accept that you are simply part of a cost benefit equation in which individual lives are being sacrificed to save money. If you agree, then you are against any sort of government run or managed, national healthcare system such as the one now emerging in the US.