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    What price reassurance?


    The occurrence of invasive breast cancer within 12 months of a mammogram was found to be 0.3% for women aged 40 to 49 and 0.4% for those aged 50 to 59 years, while ductal carcinoma in situ (DCIS) was detected relatively rarely in both groups (<0.1%). The average cost of care for each patient with invasive breast cancer was $51,837 with $3,019 in out-of-pocket expenses. Costs were greater for those aged 40 to 49 versus than for those aged 50 to 59 years ($53,894 vs $50,299), in part because younger women were more likely to undergo total mastectomies (41% vs 30.4%) and breast reconstruction (35.6% vs 25.4%).

    Based on recent literature, the authors estimated that 22% of all screen-detected invasive breast cancers were overdiagnoses and concluded that in the United States in 2012, 20,116 women aged 40 to 59 were overdiagnosed with invasive breast cancer, generating another $1 billion in unnecessary cost. For DCIS, overdiagnosis would have cost an additional $243 million. Because roughly half of these 2 combined costs can be ascribed to women aged 40 to 49, routine screening mammography in this younger group generates about $2 billion in excess costs. And that figure does not include the cost of the excess anxiety generated by false-positive results.5

    Take-home message

    In light of the reduced diagnostic efficacy of routine mammography in younger women, the lower prevalence of the disease in this group, and concerns about costs, the US Preventive Services Task Force (USPSTF) in 2009 recommended against routine mammography screening for women aged 40 to 49.6 They also recommended biennial (every 2-year) screening thereafter.

    The latest USPSTF draft recommendations, released on April 20, 2015, also do not endorse routine screening for women aged 40 to 49 but recommend informed, individualized decision-making based on a woman's “values, preferences, and health history.”7 A press release accompanying the draft recommendations explained: “For women in their 40s, the Task Force found that mammography screening every two years can also be effective and recommends that the decision to start screening should be an individual one, recognizing the potential benefits as well as the potential harms. The Task Force opined that some women in their 40s will benefit from mammography, most will not, while others will be harmed. Of the potential harms, the most serious is unneeded diagnosis and treatment for a type of breast cancer that would not have become a threat to a woman's health during her lifetime. The most common harm is a false-positive test result, which often leads to additional tests and procedures.  They also noted that, “Among women in their 40s, women who have a mother, sister, or daughter with breast cancer may benefit more than average-risk women by beginning screening before age 50. The Task Force rated this recommendation as a C, noting that mammography for women in their 40s is effective in reducing deaths from breast cancer, but that the benefits are less than for older women and the harms potentially greater.” 


    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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