False-Positive Mammograms, Overdiagnosis Cost $4 Billion
Kenneth Mandl’s slide, presented at a Health Affairs press briefing
The costs of false-positive mammograms and breast cancer overdiagnoses add up to $4 billion a year, according to a paper in the April edition of the journal Health Affairs.
The issue contains a cluster of papers focusing on the cost and quality of cancer care.
“This is imprecision medicine, where we are precisely treating the wrong patients a certain fraction of the time,” said Kenneth Mandl, professor at Harvard Medical School and the Boston Children’s Hospital Chair in Biomedical Informatics and Population Health.
One alternative approach is “personalized screening, which is based on a risk factor or a set of risk factors,” Mandl said at a press conference April 7.
The paper, co-authored by Mandl with Mei-Sing Ong, of the Boston Children’s Hospital Informatics Program, assessed the costs as the result of false-positive mammograms and breast cancer overdiagnoses among more than 700,000 women ages 40–59 between 2011 and 2013.
Average expenditures for each false-positive mammogram, invasive breast cancer, and ductal carcinoma in situ in the twelve months following diagnosis were $852, $51,837 and $12,369, respectively.
“We have to recognize that with $4 billion of revenue supporting a certain mode of operation, if we are going to change the guidelines, it would be remiss for us not to understand that there may be a revenue shift and that there may be resistance on that point,” Mandl said.
It’s not easy to explain false positives and overdiagnoses to patients, Mandl said.
“If you said ‘There is a chance that we will get a false positive, we will get through it, its going to be stressful but there is a big benefit at the end,’ versus ‘It turns out the most likely thing that will happen to you is a false-positive, a very likely thing is an overdiagnosis, and there is actually a very small percentage that can be treated, so if you did nothing,’ then a woman and her family will have a different take.”
Other papers in the cancer issue of Health Affairs include:
• Does increased spending on breast cancer treatment result in improved outcomes?
Aaron Feinstein of Yale University School of Medicine’s Cancer Outcomes, Public Policy, and Effectiveness Research Center and coauthors compared care costs and survival rates among women ages 67–94 diagnosed with stage II or III breast cancer during two time periods, 1994–96 and 2004–06.
They found that over the course of a decade, median cancer-related costs increased from $12,335 to $17,396 among women with stage II disease, and their five-year survival rate improved from 67.8 to 72.5 percent. For those women with stage III disease, costs increased from $18,107 to $32,598 with an accompanying five-year survival improvement from 38.5 to 51.9 percent.
The cost increase was largely attributable to a substantial increase in the cost of chemotherapy and radiation therapy. The authors note that the price society is willing to pay for an additional year of life remains controversial in the United States and suggest that more research is needed to determine how to best contain costs while continuing to advance patient care.
• For Uninsured Cancer Patients, Outpatient Charges Can Be Costly, Putting Treatments Out of Reach; Stacie Dusetzina of the University of Carolina at Chapel Hill and coauthors.
• Cancer Mortality Reductions Were Greatest Among Countries Where Cancer Care Spending Rose The Most, 1995–2007; Warren Stevens of Precision Health Economics, Dana Goldman of the Schaeffer Center for HealthPolicy and Economics at the University of Southern California, and coauthors.
• One of the nation’s largest fee-for-value initiatives among the first to show promise; Christy Harris Lemak of the University of Alabama at Birmingham and coauthors analyzed Blue Cross Blue Shield of Michigan’s Physician Group Incentive Program’s impact on quality and spending for more than three million beneficiaries across 11,000 primary care practices from 2008 to 2011. They found practice participation in the fee-for-value program was associated with approximately 1.1 percent lower total spending for adults and a 5.1 percent reduction in total spending for children. At the same time, the practices maintained or improved performance on eleven of fourteen quality measures—including screenings for patients with diabetes, breast and cervical cancer screenings, and well-child visits. The authors note that the findings contribute to the growing body of evidence in favor of models that align physician payment with cost and quality performance.
Publication of the cancer studies in the April issue was supported by Precision Health Economics and Celgene Corp.