The question of how often women should get mammograms remains contested, with advisory panels and medical societies disagreeing on how early and how often they should be used to find breast cancer.
But those discussions rarely mention cost. And the financial implications are huge.
If women got screening mammograms every year starting at age 40, as the American Cancer Society recommends, it would cost $10 billion a year, according to an analysis published Monday in Annals of Internal Medicine.
That's compared with $2 billion a year to screen women ages 50 to 69 every other year, or $3.5 billion to follow the recommendation of the U.S. Preventive Services Task Force. That group calls for biennial mammograms for women between the ages of 50 and 74, and screening based on personal risk factors for women under 50 and over 74.
The difference in price tags: $8 billion, or twice the annual budget of the National Cancer Institute, the world's largest funder of cancer research, according to an editorial accompanying the article.
Those numbers got Dr. Laura Esserman thinking that there might be a better way to spend some of those billions. She's a professor of surgery and radiology at the University of California, San Francisco, and the senior author of the study. Here are highlights from our conversation, edited for length and clarity.
What made you think of trying to figure out how much mammograms cost?
I first started looking at this when I was in business school in the 1990s. I got interested in looking at the different ways people approach screening in the United States and Europe. They're really quite different. What's interesting is that everyone is afraid to talk about cost. What I realized is that there really is plenty of money in the system to make changes.
What kind of changes are you talking about?
What if I told you, "OK, you can just keep doing what you're doing [for breast cancer screening], or why don't you come in and we'll do a comprehensive risk assessment?" We'll look at all the different genetic predispositions, we'll look at your breast density. Then I'll assign you an age to start mammograms and the frequency of screening, and we'll put this all in a big database and we'll learn as we go and we'll change your recommendations based on what we learn.
That sounds great. Where do I sign up?
We're starting at the end of the year in University of California Health Systems hospitals. We're trying to put all the work flow in place.
How are you going to pay for all the extra testing and counseling?
I'm actually trying to to fund it by using the money that's in the system. We'll have to raise some startup costs, but it is clear that if you do this at the end of five years it's cost-saving, even putting all the money into doing the tests and the profiling and the counseling. You'd make changes in treatment that would make it cost-saving. That's what personalized medicine is all about. We need to figure out how to do more when it's needed, and less where more only adds a burden and morbidity.
But part of that means fewer mammograms for women who are low-risk, including most women under 40 and over 75. A lot of people disagree with you on that, including the American Cancer Society.
I am actually inviting them to help me study this risk-based screening approach. These are the questions we all want to answer. I think we all can agree on that. Even without the numbers in my paper.
The weight of the evidence suggests that unless you're particularly high-risk, screening every other year is OK. Not everyone agrees. But there are implications to that. For any given person, it's not a lot of money. But if you screen 100 million women, it's a huge amount of money.
I think we need to think about health care a little bit differently. With our clinical care dollars, at least 10 percent of everything we spend should be invested in research and development, just like any innovative company. We should be looking at opportunities to improve what we do. And we should be looking for ways to use our resources better.