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Figure.  Regional Hospital Referral Region–Level Mean Breast Cancer Screening Costs per Beneficiary Screened (N = 306)
Regional Hospital Referral Region–Level Mean Breast Cancer Screening Costs per Beneficiary Screened (N = 306)

The gray areas have not been assigned to any hospital referral regions (HRRs) based on the HRR definition used by the Dartmouth Atlas (https://www.dartmouthatlas.org/downloads/atlases/96Atlas.pdf).

Table.  Annual Breast Cancer Screening Cost and Use Among Women in Their 40s With Private Insurance
Annual Breast Cancer Screening Cost and Use Among Women in Their 40s With Private Insurance
1.
US Centers for Disease Control and Prevention. Breast cancer screening guidelines for women. Accessed January 1, 2020. https://www.cdc.gov/cancer/breast/pdf/breastcancerscreeningguidelines.pdf.
2.
Mandelblatt  JS, Stout  NK, Schechter  CB,  et al.  Collaborative modeling of the benefits and harms associated with different U.S. breast cancer screening strategies.  Ann Intern Med. 2016;164(4):215-225. doi:10.7326/M15-1536PubMedGoogle ScholarCrossref
3.
Burnside  ES, Lee  SJ, Bennette  C,  et al.  Using collaborative simulation modeling to develop a web-based tool to support policy-level decision making about breast cancer screening initiation age.  MDM Policy Pract. 2017;2(2). doi:10.1177/2381468317717982PubMedGoogle Scholar
4.
Fenton  JJ, Zhu  W, Balch  S, Smith-Bindman  R, Fishman  P, Hubbard  RA.  Distinguishing screening from diagnostic mammograms using Medicare claims data.  Med Care. 2014;52(7):e44-e51. doi:10.1097/MLR.0b013e318269e0f5PubMedGoogle ScholarCrossref
5.
O’Donoghue  C, Eklund  M, Ozanne  EM, Esserman  LJ.  Aggregate cost of mammography screening in the United States: comparison of current practice and advocated guidelines.  Ann Intern Med. 2014;160(3):145-145. doi:10.7326/M13-1217PubMedGoogle ScholarCrossref
6.
Lowry  KP, Trentham-Dietz  A, Schechter  CB,  et al.  Long-term outcomes and cost-effectiveness of breast cancer screening with digital breast tomosynthesis in the United States.  J Natl Cancer Inst. 2019;djz184. doi:10.1093/jnci/djz184PubMedGoogle Scholar
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    Research Letter
    March 23, 2020

    Use and Costs of Breast Cancer Screening for Women in Their 40s in a US Population With Private Insurance

    Author Affiliations
    • 1Department of Health Management and Health Economics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
    • 2Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut
    • 3Department of Epidemiology and Biostatistics, Amsterdam UMC, Amsterdam, the Netherlands
    • 4Link Medical Research, Oslo, Norway
    • 5Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
    • 6Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
    • 7Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
    • 8Department of Population Health, New York University School of Medicine, New York
    JAMA Intern Med. Published online March 23, 2020. doi:10.1001/jamainternmed.2020.0262

    Although professional society guidelines vary, most private insurance companies in the US will reimburse for the costs of mammography for women age 40 through 49 years.1 While the clinical benefits and harms of screening women in their 40s have been widely discussed,2,3 there is limited evidence regarding the cost implications of contemporary breast cancer–screening practices among this population. We estimated annual breast cancer screening–associated costs among US women in their 40s who have private insurance. We also assessed regional variation in these costs.

    Methods

    We conducted a retrospective study of women aged 40 through 49 years who had private insurance using data from the Blue Cross Blue Shield Axis, a large commercial claims database accessed via a secure portal. We selected women between ages 40 and 49 years who were eligible to receive a screening mammography in 2017 and identified screening mammography in 2017 using a validated algorithm and relevant Current Procedural Terminology codes.4 For each beneficiary screened, we identified subsequent evaluation tests in the 4 months after the initial screening mammography and calculated the total annual cost of screening based on use and unit costs of initial screening (2-dimensional mammography with or without digital breast tomosynthesis [DBT]), supplementary screening (screening ultrasonography), recall (diagnostic 2-dimensional mammography with or without DBT and ultrasonography), and other diagnostic tests (magnetic resonance imaging and biopsy). We then estimated the mean cost per beneficiary screened.

    To estimate national screening costs, using a previously applied approach,5 we multiplied the total national number of women with private insurance who were aged 40 through 49 years and eligible for breast cancer screening by the proportion of women screened and the mean per-beneficiary-screened cost of screening derived from our study. To examine regional variation, we estimated the mean total per-beneficiary-screened cost for each hospital referral region (HRR), and evaluated variation in these estimates across HRRs (eAppendix in the Supplement). The Human Investigation Committee of Yale School of Medicine approved this study as exempt (in a category for research with deidentified secondary data); thus, informed consent was not needed. Analyses were performed using SQL Server Management Studio version 17.0 (Microsoft), STATA/MP version 14.1 (StataCorp), and R version 3.5.3 (R Foundation for Statistical Computing).

    Results

    Our study cohort included 2 257 393 women aged 40 to 49 years. Of these women, 930 526 (41.2%) were screened with mammography in 2017, 543 380 (24.1%) with 2-dimensional mammography, and 387 146 (17.2%) with DBT (Table). Among the 930 526 women who had a screening mammography during the study period (either with or without DBT), 137 764 (14.8%) were recalled for diagnostic evaluation and 20 229 (2.2%) were referred for other diagnostic tests (Table).

    The mean cost of breast cancer screening was $353 per beneficiary screened (Table). The main contributor to this mean (SD) cost was initial screening mammography (mean [SD] per-person cost, $249 [$125]) followed by recall (mean [SD] per-person cost, $56 [$172]) and other diagnostic tests (mean [SD] per-person cost, $45 [$421]). The median cost of breast cancer screening was $250 (interquartile range, $174-367) per beneficiary screened (Table). When extrapolating these costs to the population who have private insurance in the US, the total national cost of screening women in their 40s was $2.13 billion per year, most of which was accounted for by the initial screening mammography ($1.50 billion; Table).

    There was substantial regional variation in breast cancer screening costs. The total annual mean (SD) costs of breast cancer screening varied from $151 ($258) to $751 ($1100) per beneficiary screened across HRRs (Figure).

    Discussion

    We found that although fewer than half of the women aged 40 through 49 years who had private insurance and were eligible received annual breast cancer screening in 2017, the estimated annual national cost was $2.13 billion. These costs are borne despite the unclear tradeoff between clinical benefits and risks of screening women aged 40 through 49 years. Furthermore, the cost per beneficiary screened varied 5-fold across regions. Of note, the costs identified in this study were substantially higher than estimates used in previous cost analyses (eg, 2-dimensional mammography unit cost: $213 in this study, compared with $140-$155 in prior studies).5,6 Our data add clarity around the costs of breast cancer screening for women in their 40s, drivers of these costs, and magnitude of regional variation. They can help inform policy-makers’ decisions and future cost-effectiveness evaluations to optimize resource allocation.

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    Article Information

    Accepted for Publication: January 25, 2020.

    Corresponding Author: Natalia Kunst, MSc, Department of Health Management and Health Economics, Institute of Health and Society, Faculty of Medicine, University of Oslo, PO Box 1089, Blindern, Oslo 0317, Norway (natalia.kunst@medisin.uio.no; natalia.kunst@yale.edu).

    Published Online: March 23, 2020. doi:10.1001/jamainternmed.2020.0262

    Author Contributions: Dr Long had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Kunst, Busch, Kyanko, Gross.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Kunst.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Kunst, Long, Busch.

    Administrative, technical, or material support: Kunst, Kyanko, Gross.

    Supervision: Gross.

    Conflict of Interest Disclosures: Ms Kunst reported funding from the Research Council of Norway (276146 and 304034) and Link Medical Research during the conduct of the study. Dr Xu reported receiving research support through Yale University from the Centers for Medicare & Medicaid Services to develop and maintain performance measures, and research grants from the American Cancer Society, the National Institutes of Health, and the Agency for Healthcare Research and Quality during the conduct of the study. Dr Busch reported receiving research grants from the National Institute of Health, the Robert Wood Johnson Foundation, the Donaghue Foundation, and the American Cancer Society during the conduct of this study. Dr Kyanko reported receiving research support through Yale University from the Centers for Medicare & Medicaid Services to develop and maintain hospital performance measures during the conduct of the study. Dr Richman reported receiving grants from the National Institutes of Health/National Center for Advancing Translational Sciences during the conduct of the study and personal fees from the Centers for Medicare & Medicaid outside the submitted work. Dr Gross reported receiving a research grant National Comprehensive Cancer Network/Pfizer, funding from Johnson & Johnson to assist with developing new approaches to sharing clinical trial data (through the Yale Open Data Access Project), and funding from Flatiron Inc for travel and speaking outside the submitted work. No other disclosures were reported.

    Funding/Support: Funding for this work was provided the National Institutes of Health/National Center for Advancing Translational Sciences (grant KL2 TR001862 [Dr Richman]) and the American Cancer Society (grant RSGI-15-151-01 [Dr Gross]). Ms Kunst's effort on this work was funded by the Research Council of Norway and LINK Medical Research (grants 276146 and 304034).

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    US Centers for Disease Control and Prevention. Breast cancer screening guidelines for women. Accessed January 1, 2020. https://www.cdc.gov/cancer/breast/pdf/breastcancerscreeningguidelines.pdf.
    2.
    Mandelblatt  JS, Stout  NK, Schechter  CB,  et al.  Collaborative modeling of the benefits and harms associated with different U.S. breast cancer screening strategies.  Ann Intern Med. 2016;164(4):215-225. doi:10.7326/M15-1536PubMedGoogle ScholarCrossref
    3.
    Burnside  ES, Lee  SJ, Bennette  C,  et al.  Using collaborative simulation modeling to develop a web-based tool to support policy-level decision making about breast cancer screening initiation age.  MDM Policy Pract. 2017;2(2). doi:10.1177/2381468317717982PubMedGoogle Scholar
    4.
    Fenton  JJ, Zhu  W, Balch  S, Smith-Bindman  R, Fishman  P, Hubbard  RA.  Distinguishing screening from diagnostic mammograms using Medicare claims data.  Med Care. 2014;52(7):e44-e51. doi:10.1097/MLR.0b013e318269e0f5PubMedGoogle ScholarCrossref
    5.
    O’Donoghue  C, Eklund  M, Ozanne  EM, Esserman  LJ.  Aggregate cost of mammography screening in the United States: comparison of current practice and advocated guidelines.  Ann Intern Med. 2014;160(3):145-145. doi:10.7326/M13-1217PubMedGoogle ScholarCrossref
    6.
    Lowry  KP, Trentham-Dietz  A, Schechter  CB,  et al.  Long-term outcomes and cost-effectiveness of breast cancer screening with digital breast tomosynthesis in the United States.  J Natl Cancer Inst. 2019;djz184. doi:10.1093/jnci/djz184PubMedGoogle Scholar
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