Mammograms: Is It About Money?

Nov. 19, 2009 — -- The 16-member U.S. Preventive Services Task Force released its new recommendations on mammograms two days ago -- and the resulting firestorm has yet to die down. Doctors and patients are expressing outrage that a government panel would dare adjust the mammogram guidelines. The current standard recommends annual screenings for women 40 and older; the revised recommendations push that age out to 50 and recommended screenings every other year.

In a response that was typical of many in the medical profession, Dr. Daniel Kopans, head of breast imaging at Massachusetts General Hospital, said, "I think it is outrageous to reduce costs by taking away a test that is saving lives and saving a large number of lives."

But the recommendations aren't for taking away the test, only changing the guidelines for when testing should begin.

In addition, while there is no question that mammograms save lives, there is a very real debate about the cost incurred in screening all women every year between the ages of 40 and 50.

"Every medical care system in the world has a concern about not paying for things that shouldn't be done," said professor Theodore Marmor, a health care policy specialist at Yale University.

Statistics from the National Cancer Institute show that the risk a woman of 40 will be diagnosed with breast cancer before she turns 50 is relatively low – less than 2 percent. But the false positive rate for those same women is relatively high – 50 percent higher than women in their 50s.

And those women are likely to undergo further, more expensive, procedures -- only to find out they are, in fact, healthy.

"Although screening every woman between the ages of 40 and 50 would turn up some breast cancer…the question is what is the cost per diagnosis per relevant harm," said Marmor.

If that calculus sounds cold, it shouldn't. That kind of cost-benefit analysis is, in fact, already routine in the health insurance industry.

"The question is going to be, between the ages of 40 and 50, what is the frequency with which you are going to find a true positive cancer finding, how many cases would we miss, how many of those cases would develop into cancer and what is it going to cost to treat them," said Ian Duncan, president of Solucia, a company that provides actuarial health care analysis for insurers.

But some have cited that the new research does not consider the impact of newer technologies in breast cancer screening. The authors themselves admit that the recommendations were limited because "studies of older women, digital mammography and magnetic resonance imaging are lacking."

Digital mammograms are 1.5 to 4 times more expensive than conventional film-based mammograms, according to the National Cancer Institute, which also reported in 2005 that only 8 percent of the country's breast imaging units provide the technique.

But digital mammograms are thought to be more effective at screening women in their 40s. The NCI points to a large clinical trial in 2001, which showed digital mammography was sensitive enough that it performed "significantly better in screening women ... under age 50."