Opportunity cost of annual screening mammography

Arleo et al used Cancer Intervention and Surveillance Modeling Network (CISNET) computer modeling to compare the benefit and harms from 3 different screening recommendations from the American College of Radiology (ACR), the American Cancer Society (ACS), and the US Preventive Services Task Force (USPSTF). Mandelblatt et al modeled multiple screening strategies ending at age 74 years and by comparing life-years gained with mammograms performed found that both the ACR and USPSTF strategies were efficient, whereas hybrid strategies such as that of the ACS were not. The ACR recommendation for annual screening starting at age 40 years and ending at age 84 years was found to have a greater benefit in breast cancer mortality reduction in both analyses compared with that of the USPSTF (biennial, ages 5074 years) (38/26 vs 40/23), as would be expected. Arleo et al did not provide the incremental benefit of annual screening beyond age 74 years in terms of relative or absolute risk reduction. The previous CISNET modeling of overdiagnosis in this older age group did not use annual screening and did not account for resource costs. Therefore, an annual or biennial screening strategy for older women is not necessarily cost-effective, and is not based on evidence from the randomized trials. Advocates for aggressive screening schedules must account for overdiagnosis, which harms a percentage of healthy women and negates the breast cancer mortality benefit. Advocates for any health intervention also must consider the opportunity cost of the resources used, which often is done through cost-effectiveness analyses. Using CISNET models, Stout et al calculated a median of $250,000 per quality-adjusted life-year incremental gain using the ACR strategy up to age 74 years instead of the USPSTF strategy, using conservative Medicare cost inputs. The inclusion of negative quality-of-life adjustments from screening and false-positive mammograms would increase the ratio from 20% to 70%. Radiologists could help to quantify the disutility from false-positive recalls and benign biopsies. O’Donoghue et al previously reported that adopting the ACS ($10.1 billion) versus the USPSTF ($3.5 billion) strategy would generate additional direct screening costs of >$6.6 billion in the United States in 2010. Assuming that average cost inputs based on insurance reimbursement data are 70% higher, this result increases to $11.2 billion in 2013 dollars. Adjust for 100% instead of 85% participation and the Consumer Price Index increases the total difference in strategies to $14.7 billion in 2017 dollars. This additional resource cost is direct revenue to the >8500 screening facilities (average, $1.7 million) and associated radiologists in the United States. Recall rates from US insurance claims data already are between 13% to 19%, which is higher than the Breast Cancer Surveillance Consortium data used in the CISNET models. Decreasing the US false-positive rate from 15% to 10% would save at least $1.3 billion annually, which is enough to treat 25,000 women with invasive cancer. Accepting the 2-year screening intervals recommended by the USPSTF would help radiologists in the United States move toward the more efficient European recall performance rate of <5%. Women considering screening mammography and politicians mandating insurance benefits should be aware of the financial incentives that influence screening recommendations from panels with conflicts of interest.