Areas in the country that spend more on new screening technologies such as digital mammography are seeing more women diagnosed in the early stages of breast cancer but no corresponding drop in late-stage breast cancer diagnoses, according to a study published Monday that raises questions about the benefits of the new tools.
Yale University researchers reviewed a 2006 government Medicare database of more than 137,000 women ages 66 to 100 who hadn’t been diagnosed with breast cancer and found that the Medicare program spent more than $1 billion that year on mammography screening, they reported in the journal JAMA Internal Medicine.
But spending varied based on where women lived. Different regions of the country spent anywhere from $42 to $107 per Medicare beneficiary on breast cancer screening. Much of the difference in cost was due to variations in the adoption of newer technologies such as digital mammograms and software tools designed to improve the X-rays’ detection rate.
Women in high-cost areas that used the most advanced screening were 78 percent more likely to be diagnosed with early-stage breast cancer but weren’t any less likely to be diagnosed with advanced disease. An additional 1 per 1,000 women screened in the high-cost areas was diagnosed with breast cancer over the two-year study without a significant decline in advanced cancers— ones more likely to be fatal because they had spread to distant parts of the body.
“We feel that results of our study really call for further assessment of which new technologies should be available for cancer screening,” said study author Dr. Carey Gross, an associate professor of medicine at the Yale University School of Medicine, “and which older patients are going to benefit from it.”
In an editorial that accompanied the study, Georgetown University breast oncologist Dr. Jeanne Mandelblatt and her colleagues wrote that the new finding was “compelling” but “does not fully address the question of whether investment in more expensive digital technology improves breast cancer outcomes for older women.” That’s because it didn’t follow women long enough to see whether spending more on mammography actually reduced breast cancer death rates.
Most radiology centers now routinely use digital mammograms, but some are starting to adopt more advanced screening devices such as 3-D mammography, which X-rays the breast from various angles and detects more early breast cancers than digital X-rays.
For women age 75 and over, in particular, there’s little evidence that annual mammograms lower their risk of dying from breast cancer, which led a government task force in 2009 to stop recommending screening for women in this age group.
That lack of evidence may be partly due to a dearth of older women in mammography screening trials, Gross said.
The latest research adds to growing concerns about the increasing numbers of women diagnosed with tiny breast malignancies that might never have grown large enough to be felt or posed any life-threatening risk. A November analysis from Dartmouth researchers estimated that 1 million American women had been overdiagnosed with breast cancer over the past 30 years.
The study also highlighted the costs of cancer screening in populations that might receive little benefit. Medicare spends $410 million every year to cover the costs of breast screening in women age 75 and over.
Women need to be informed about the complexities of breast screening—that its potential life-saving benefits diminish with a woman’s life expectancy—before a referral slip is written for a mammogram, said Dr. Leigh Simmons, an internist at Massachusetts General Hospital. For older women in failing health because of heart disease or some other chronic condition, an annual mammogram might not make any sense.
On the other hand, a 75-year-old healthy active woman, who could easily live another two decades, may want to continue having her yearly screenings, Simmons said.
“I have this conversation a lot with my patients,” she said, “but it’s a scary conversation to have because we’re confronting a patient’s mortality.”
Dr. Mara A. Schonberg, an internist at Beth Israel Deaconess Medical Center who studies breast cancer screening and treatment in elderly women, said she spends a lot of time counseling older women on the limited benefits and established drawbacks of mammography, especially if they already have a life-threatening health condition. “Biopsies can be very anxiety-provoking regardless of a woman’s age, and doctors tend to treat women over 80 for breast cancer just the same as they would a 50-year-old.”
They might give such patients chemotherapy or anti-estrogen therapies, with all their side effects, to prevent a recurrence years down the road.
Simmons said she’s been having more discussions lately with patients about unnecessary health care costs. “They’ve been asking me if the test I’m ordering is really worth it, and whether it’s excessively expensive even if it’s covered by their insurance,” she said. “I think the conversation is changing as patients realize that we’re all in this together and we need to be using our resources wisely.”