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    What price reassurance?


    The cost of false-positives and overdiagnosis

    Ong and Mandl conducted a retrospective cohort study of 702,154 women aged 40 to 59 years who underwent routine mammography during a 12-month period. The researchers used insurance data to calculate the expense of false-positive mammograms and breast cancer overdiagnoses.4 They included beneficiaries from all 50 states and the District of Columbia undergoing such screening in 2012 who were continuously enrolled in the insurance plan for the following 12 months. They excluded high-risk women, including those with a prior diagnosis of breast cancer.

    The authors defined a “false-positive mammogram” as one that led to a further diagnostic workup that was not followed by a breast cancer diagnosis. Women with invasive breast cancers were identified by the ICD-9 code for invasive breast cancer (174.x) as well as by evidence of subsequent breast cancer treatment (ie, surgery, radiation therapy, or chemotherapy). Women with ductal carcinoma in situ (DCIS) were also defined by ICD-9 code (233.0). Since the authors could not ascertain from insurance claims which breast cancers had been overdiagnosed, they used published rates to estimate this occurrence. They then estimated annual national costs by applying the false-positive rate derived from their analysis and overdiagnosis rates reported in the recent literature to their average cost data, extrapolating these costs to the number of women screened annually in the United States.

    Related: More money spent on breast Ca screening may not lead to better outcomes 

    The authors reported that 77,729 women (11.1%) had a false-positive mammogram result requiring a further diagnostic workup and breast-related procedures. Defining breast ultrasound and magnetic resonance imaging as part of that work-up increased the number of false-positive mammogram results to 91,501 (13%). As expected, women aged 40 to 49 years were more likely to have a false-positive result than were those aged 50 to 59 years (14.4% vs 11.6%, odds ratio 1.25; 95%CI: 1.23–1.26). Among those with a false-positive mammogram, a biopsy was performed in 29.3% of cases and 0.4% of patients underwent a prophylactic mastectomy.

    The average cost per beneficiary for a false-positive result was $852, with $200 in out-of-pocket expenses. Given that there are about 21.2 million women aged 40–49 and 22.4 million aged 50–59 in the United States, and assuming 62.3% and 72.6% of these 2 cohorts, respectively, undergo mammography screening each year, 29.5 million women would be screened. Given an 11% false-positive rate, 3.2 million would undergo unnecessary studies for a total cost of $2.8 billion per year. Using these data, women aged 40 to 49 years would generate $1.24 billion per year in excess costs from false-positive mammograms.

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...


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