Study Examines Costs of Breast Cancer Screening in Medicare Recipients


Media Advisory: To contact Cary P. Gross, M.D., call 203-432-1326 or email To contact commentary author Jeanne S. Mandelblatt, M.D., M.P.H., call Karen Mallet at 215-514-9751 or email

CHICAGO – Breast cancer screening costs in the Medicare program topped $1 billion annually in the fee-for-service program during 2006 to 2007, with substantial regional variation driven by newer and more expensive technologies, although it is unclear whether higher screening costs achieve better breast cancer outcomes, according to a report published Online First by JAMA Internal Medicine, a JAMA Network publication.


Newer breast cancer screening technologies, such as digital mammography and computer-aided detection (CAD) have expanded the options available to clinicians, however using these new technologies can increase costs directly through reimbursement for the tests and also lead to higher rates of supplemental imaging, biopsy or cancer detection. Assessing the relationship between screening expenditures and population outcomes is important because newer technologies can increase cancer detection rates but may not improve outcomes, especially among older women, the authors write in the study background.


Cary P. Gross, M.D., of the Yale University School of Medicine, New Haven, Conn., and colleagues utilized the linked Surveillance, Epidemiology, and End Results-Medicare database to identify 137,274 women ages 66 to 100 years who had not had breast cancer and to assess the cost to fee-for-service Medicare of breast cancer screening and workup during 2006 to 2007. Researchers also examined screening-related cost at the Hospital Referral Region (HRR) level and evaluated the association between regional expenditures and workup test utilization, cancer incidence and treatment outcomes.


“We found that the Medicare fee-for-service program is spending over $1 billion per year on breast cancer screening and workup of suspicious lesions. This accounted for over 45 percent of the $2.42 billion total spent by Medicare on screening and the initial treatment phase of breast cancer, suggesting that analyses that focus exclusively on treatment have overlooked a significant contributor to cancer costs,” the authors comment.


Additionally, study results indicate that for women 75 years or older, annual screening-related expenditures topped $410 million. Age-standardized screening-related cost per beneficiary varied more than two-fold across regions (from $42 to $107 per beneficiary); and digital screening mammography and CAD accounted for 65 percent of the difference in screening-related cost between HRRs. Women living in HRRs with high screening costs were more likely to be diagnosed as having early-stage cancer (incidence rate ratio, 1.78). There was no significant difference in the cost of initial cancer treatment per beneficiary between the highest and lowest screening cost HRRs ($151 vs. $115), according to the study results.


“In summary, the costs of breast cancer care in the Medicare population, when incorporating screening costs, are substantially higher than previously documented and the adoption of newer screening modalities will likely contribute to further growth,” the authors conclude. “The growth trajectory may be steeper than projected owing to Medicare’s reimbursement strategy, which supports rapid adoption of newer modalities, frequently without adequate data to support their use.”

(JAMA Intern Med. Published online January 7, 2013. doi:10.1001/jamainternmed.2013.1397. Available pre-embargo to the media at


Editor’s Note:  The authors made a number of conflict of interest and funding/support disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding andsupport, etc.


Commentary: Costs, Evidence, Value in the Medicare Program


In an invited commentary, Jeanne S. Mandelblatt, M.D., M.P.H., of Georgetown University, Washington, and colleagues write: “Although the evidence from this study is compelling, it does not fully address the question of whether investment in more expensive digital technology improves breast cancer outcomes for older women. They used incidence of early- vs. late-stage disease as their primary measure of effect.”


“Clinical trials specific to older populations could begin to address the limitations inherent in all good observational research, including that of Gross et al. … But, until we invest in conducting a definitive randomized trial in older women, we will continue to grapple with the conundrums inherent in interpreting observational results like those of Gross et al,” they continue.


“For all of these conditions, interventions, and decisions about Medicare coverage, the real question raised by the research of Gross et al that must be answered is how we put a value on the life of any person or group,” they authors conclude.

(JAMA Intern Med. Published online January 7, 2013. doi:10.1001/jamainternmed.2013.2127. Available pre-embargo to the media at


Editor’s Note: The authors are supported by funding from the National Cancer Institute at the National Institutes of Health. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding andsupport, etc.

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