The Hidden Cost of Mammograms: More Testing and Overtreatment

Instead of having mammograms according to age, some doctors think screening should be based on a woman's overall risk for breast cancer. (Getty Images)

Instead of having mammograms according to age, some doctors think screening should be based on a woman’s overall risk for breast cancer. (Getty Images)

By Patti Neighmond, NPR

There’s no question mammograms can save lives by detecting breast cancer early. But they can also result in unnecessary testing and treatment that can be alarming and costly.

In fact, each year the U.S. spends $4 billion on follow-up tests and treatments that result from inaccurate mammograms, scientists report in the current issue of Health Affairs.

That’s a “stunning number,” says the study’s lead author, Dr. Kenneth Mandl, at Harvard Medical School’s Center for Biomedical Informatics.

Mandl and a colleague analyzed the insurance records of more than 700,000 women from 2011 to 2013. The women were between the ages of 40 and 59, and they all had routine mammograms to screen for breast cancer during that time period. Continue reading

Digital Mammograms: Pricey And Perhaps No Better for Older Women

In the U.S. 95 percent of mammography machine are now digital.(Mychele Daniau/AFP/Getty Images)

In the U.S. 95 percent of mammography machine are now digital.(Mychele Daniau/AFP/Getty Images)

By Kara Manke, NPR

Medicare spending on breast cancer screening for women age 65 and older has jumped nearly 50 percent in recent years. But the rise in price was not associated with an improvement in the early detection of breast cancer.

“We did not see a change in the detection of early or late stage tumors.”

Researchers at the Yale School of Medicine found that Medicare spending on breast cancer screening rose from $666 million in the years 2001-2002 to $962 million in the years 2008-2009.

So why the big increases in costs?

“The way that we screen for breast cancer has changed dramatically,” explains Yale’s Dr. Cary Gross, an internist and a co-author of the study. The study was published this week in the Journal of The National Cancer Institute. Continue reading

50-Year Review: Mammography Benefits Oversold, Harms Minimized

(Getty Images)

(Getty Images)

By Nancy Shute, NPR

Two months ago, a widely publicized Canadian study found that mammograms did not reduce breast cancer deaths, but that study was fiercely criticized by the nation’s radiologists as “incredibly flawed and misleading.”

A few weeks earlier, an analysis found that screening all women annually starting at age 40, as the American Cancer Society recommends, costs $6.5 billion more a year more than following the U.S. Preventive Service’s Task Force recommendation that women be screened every other year starting at age 50.

Now, the latest entries — two studies that try to put all the previous research on mammography’s harms and benefits in perspective.

First, researchers at Harvard took a broad look at all the research on mammograms since 1960 — more than 50 years of study. They also looked at evidence on the harms of false positives and overdiagnoses, in which a woman is treated for a cancer that would never have proved deadly. And they reviewed whether current efforts to try to personalize a woman’s cancer risk helped a woman figure out whether it was worth her while to get a mammogram. Continue reading

In Light of the Mammogram Study: Two Thoughts on Breast Cancer

(Getty Images)

(Getty Images)

More evidence is in this week that casts doubt on the value of mammograms. To recap: Canadian researchers followed nearly 90-thousand women since the 1980s. The women were randomly assigned to mammography or physical breast exam. Now 25 years later, the researchers say that roughly equal numbers of women in each group died of breast cancer — mammography, according to this study, is not affecting the death rate at all.

In addition, mammography comes with harms. More than 1 in 5 cancers found in the mammography group were not ones that pose a threat to women’s health, the researchers say. Doctors call this “overdiagnosis.” This is a problem because the treatments for cancer are aggressive — surgery, radiation therapy, chemotherapy — and can cause harms in and of themselves. “There is no question that there is an excess in the diagnosis of tumors that are not going to kill you,” Dr. Laura Esserman, head of the UC San Francisco breast care center, told me, “We all know this phenomenon exists, but this quantifies it.”

Those are the headlines. Thursday morning, KQED’s Forum got into more detail. I was particularly interested in two points the guests made. The first was about new approaches to screening and the second was about screening as distinguished from prevention. Continue reading

The Cost of Mammograms: Is A Picture Worth $7 Billion?

(Getty Images)

(Getty Images)

The issue of how often a woman should be screened for breast cancer has been a topic of hot debate for years. But of the many different issues that are closely examined, cost is rarely among them.

Even mentioning cost typically gets patients somewhat understandably up in arms — no one wants her life to be determined by mere dollars.

But what if those dollars are being spent poorly? The harms of mammograms are well-known — false positives and overtreatment among them. What if reconsidering what we’re doing and how we’re doing it could actually lead to more lives saved?

Into the fray comes an analysis from several researchers, including Dr. Laura Esserman, a breast cancer surgeon with UCSF. They calculated the costs for screening mammography in the U.S. under different scenarios. Continue reading

Berkeley Journalist Takes On The ‘Feel-Good War on Breast Cancer’

The article asks: (Photo/Getty Images)

(Photo/Getty Images)

I first saw the article Thursday night on Facebook, then stayed up until midnight reading it. In a helluva story, Peggy Orenstein addresses The Feel-Good War on Breast Cancer in this Sunday’s New York Times Magazine.

Orenstein is uniquely situated to write an article she hopes will “help change the national conversation.” She’s been treated for breast cancer twice in the last 15 years, including a mastectomy last fall, and the Times Magazine — for which she writes regularly — is one of the most powerful publications in the world.

Orenstein was first diagnosed with breast cancer in 1997 after her doctor sent her for a screening mammography. “I used to believe a mammogram saved my life,” she writes as the opening line of her piece. Today, she’s not so sure.

As she writes in the Times:

Sixteen years later, my thinking has changed. As study after study revealed the limits of screening — and the dangers of overtreatment — a thought niggled at my consciousness. How much had my mammogram really mattered? Would the outcome have been the same Continue reading

California’s Breast Density Notification Law Goes Into Effect

(Photo: U.S. Navy)

(Photo: U.S. Navy)

As women are well aware, the purpose of a mammogram is to screen for cancer. What many women don’t know is that as part of the screening, radiologists also assess the level of density in a woman’s breast tissue.

Starting Monday, a new California law will require that doctors notify women if their breast tissue is dense. Dense breast tissue makes it harder to read mammograms and is associated with an increased risk of breast cancer.

Former state Sen. Joe Simitian (D-Palo Alto) introduced the law last year. It grew out of his concern that while doctors were aware of a patient’s breast density, the patient herself was not, preventing women from talking with their doctors about how they might want to address their potential increased risk. He wanted to change that.

“The fundamental premise of the legislation,” he said in a recent call with reporters, “is that absent this information, these conversations weren’t going to take place.”

Some background: breast tissue is graded from 1 (not dense) to 4 (extremely dense). The law requires that women graded either a 3 or a 4 be notified.

Here’s the specific notification required by the law:

Your mammogram shows that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the Continue reading

Mammograms: Which Women? How Often?

(Photo: U.S. Navy)

(Photo: U.S. Navy)

As everybody knows by now, how frequently a woman should have a mammogram is a topic of hot debate in the U.S. In particular, women in their 40s have been troubled by recommendations almost four years ago from the U.S. Preventive Services Task Force that mammograms are not routinely recommended for them. Instead, the decision is an “individual one” that a woman can make, presumably in conversation with her doctor.

Now, a new study has a tailored recommendation. For women in their 40s with “extremely dense breasts,” annual screening will reduce their risk of being diagnosed with advanced stage breast cancer.

“There is this sub-group that is higher risk and has more aggressive tumors,” said lead researcher Karla Kerlikowske, an epidemiologist and biostatistician at UCSF. “Annual mammography is probably better for that group.”

To date, most recommendations have relied on one risk factor: age. A woman’s risk of breast cancer increases as she gets older. But there are other risk factors, too, like breast density. About 12 to 15 percent of women in their 40s have “extremely dense breasts.” Radiologists categorize breast density on a scale of 1 to 4, and a score of 4 is “extremely dense.”

Continue reading

Mammograms: Strong Evidence That Every Two Years Is Best Option For Older Women

(Photo: U.S. Navy)

(Photo: U.S. Navy)

A major new study has found that — in older women — mammograms done every two years were as effective as mammograms done annually and led to far fewer false positive results.

The study, published online Tuesday in the Journal of the National Cancer Institute, included more than 140,000 women ages 66 to 89 from across the country.

Frequency of mammograms among women in their 40s and 50s has been the subject of intense debate for more than two decades, but this older group of women has been much less studied.

The women screened annually had a dramatically higher rate of false positives.
A team led by researchers at UC San Francisco sought to answer the question: among older women, if a woman is screened for breast cancer every two years, instead of every year, will a deadly cancer be missed?

“We found that there really was no difference,” Dejana Braithwaite, assistant professor of cancer epidemiology at UCSF and part of the research team, told me. “The women who were screened every two years were not at a greater risk. They did not have a higher probability of being diagnosed with late stage breast cancer compared to those women who were screened every year.” Continue reading

New Mammogram Research for Women in Their 40s

(Photo:  U.S. Navy)

(Photo: U.S. Navy)

It’s hard to believe that a one in a hundred risk of something bad happening would generate so much heated debate, but that’s where we’re at when it comes to the question of mammograms for women in their 40s. Since breast cancer is a disease which risk increases with age, the clear cut off point for mammography has been age 50. Mammography will find cancer in women in their 40s, but will carry a much higher risk of false positives.

Specifically, a 40-year-old woman has a 1.5 percent chance of developing breast cancer at some point during her 40s. The 1-in-8 chance repeated so frequently is over a lifetime — up to age 80.

While mammography is the best tool we have in detecting breast cancer, it’s not a perfect test. Mammograms will pick up abnormalities that are not breast cancer. The problem is that doctors can’t say definitively these abnormalities are benign without further testing. Sometimes that means having an additional mammogram, sometimes women must then have a biopsy. In the meantime, many of these women are worrying. Continue reading