Today’s Managing Health Care Costs Number is $400 million
It’s not been a good month for mammography. Two important pieces of research were published that cast doubt on the overall benefit of mammography, and on computer aided detection to augment digital mammography.
Researchers from Dartmouth and Harvard reported in September’s JAMA Internal Medicine that counties with higher rate of mammography have more diagnosed breast cancer – but they have breast cancer mortality which is indistinguishable from counties with low rates of mammography. Screening finds many more cancers, and many more cancers are treated, but that doesn’t appear to have any impact on death rtes. There were many more small breast cancers found in the high screening counties (25%), but there was also a statistically significantly larger number of large breast cancers found (7%).
This doesn’t prove that mammograms don’t sometimes save lives. The study only covered ten years, and the benefit could have been later. It just shows that over the American population the amount of lives saved by mammography are very unlikely to be large. Further, it casts doubt on the massive effort to increase mammography screening.
Researchers in JAMA last week showed that mammograms augmented with computer aided detection (CAD) did not improve breast cancer diagnosis compared to mammograms without this additional service (and fee.). CAD was associated with statistically insignificant lower sensitivity and lower sensitivity for invasive cancer. It did find significantly more cases of ductal carcinoma in situ; the treatment of DCIS is controversial and it’s likely that much of this is overdiagnosis. CAD technology is used on 83% of all mammograms, and costs insurers $400 million.
An accompanying editorial advocated that Medicare and insurers stop paying additional fees for CAD – but there are two problems. It’s very hard to stop paying for something that’s been a covered service for 17 years – and we wouldn’t want to see radiologists billing women directly for these services. The other problem is that for radiologists mammography isn’t especially lucrative, so pulling this fee could decrease access. On the other hand, research shows us that we should probably do fewer mammograms than were recommended in the past, so perhaps this is just fine.
From the JAMA editorial:
Congress should therefore rescind the Medicare benefit for CAD use. If we could curtail use of many similarly ineffective tests and interventions, we could significantly reduce US health care expenditures while augmenting resources for effective care or well-designed studies of promising innovations. Savings from a single year of CAD use, for example, could fund a much-needed clinical trial comparing screening outcomes with mammography vs mammography with breast tomosynthesis. The lesson of CAD is that broad societal investment in new medical technologies should occur only after large-sample evaluations prove their real-world effectiveness and justify their costs.
