Anees B. Chagpar, MD, MSc, MPH, MA, MBA
Associate Professor, Department of Surgery
Director, The Breast Center, Smilow Cancer Hospital at Yale-New Haven
Assistant Director for Diversity and Health Equity, Yale Comprehensive Cancer Center
Program Director, Yale Interdisciplinary Breast Fellowship
Yale University School of Medicine
New Haven, CT
It is well known that healthcare spending in the United States is unsustainable. It is also well known that despite spending a record $2.8 trillion on healthcare annually (17.2% of GDP in 2012)—more than any other nation—our health outcomes lag behind.1
Certain patterns in breast cancer care serve as a microcosm of this debacle. How we screen and work up the more than 235,000 people who are diagnosed with breast cancer every year2
, and provide surveillance for the more than 2.8 million breast cancer survivors in this country3
remain a source of considerable controversy and variation in terms of cost.
Yet, there are evidence-based guidelines that provide a more value-based approach that may more aptly address the triple aim of providing the best care, at the lowest cost, for the entire population.4Screening
When to start screening, with what modality, how frequently, and when to stop continue to be questions that oncologists face. The 2009 United States Preventive Services Task Force (USPSTF) recommendations, which caused quite an uproar, noted that the majority of the data from randomized controlled trials demonstrating the benefit of mammography were generatedin women between the ages of 50 and 74 years. Furthermore, the recent Canadian randomized controlled trial of nearly 90,000 women followed for more than 20 years demonstrated no improvement in survival and a 22% overdiagnosis rate for women aged 40 to 59 years who underwent screening mammography.5
Nonetheless, the American Cancer Society, the National Comprehensive Cancer Network, and the 2002 USPSTF guidelines (now accepted by the Affordable Care Act) all endorse the traditional standard of screening with annual mammography for all women over the age of 40 years.
When to stop screening is also controversial, since there is insufficient evidence of additional benefit or harm in women over the age of 75 years; however, the annual cost for screening in this population exceeds $410 million.6
This is not to argue that no woman over this age should have a mammogram; rather, the decision to screen in this population should be individualized based on patient comorbidities and desires.It makes little sense to screen patients who would likely elect not to treat a small area of cancer or ductal carcinoma in situ detected through a mammogram.
How we screen for breast cancer has also been the subject of some debate. Recent studies have found that the cost of screening in the Medicare population has increased over time, largely due to newer technology, with no significant stage migration.7
The addition of screening ultrasound, particularly for women with dense breasts, may be useful, and the introduction of tomosynthesis holds promise to find more cancers earlier with fewer call-backs. Yet, one wonders about the true effect of all of these screening efforts in reducing mortality due to breast cancer given that, despite an increase in early-stage breast cancers, there has not been a similar concomitant decline in advanced malignancy over the past three decades.8Workup
Once patients are diagnosed with cancer, how patients are worked up for extent of disease is another area of considerable controversy. While some have continued to order routine breast MRI, it has become increasingly clear that such practices do not improve outcomes. Adding to the COMICE9
trial data that MRI does not decrease re-excision rates, a recently published individual meta-analysis found that there was no reduction in local or distant recurrence with the use of preoperative MRI.11
Certainly, there will be some patients who will benefit from the addition of MRI, but to have a “one size fits all” approach to preoperative workup seems rather simplistic.
The Cost of A Long Life
The chart illustrates the top 30 countries in the world ranked by life expectancy and corresponding healthcare spending based on 2000 statistics. The international dollar is a hypothetical unit of currency that compares what a dollar would buy in goods and services in a given country with comparable purchases that a US dollar would buy in the United States.
Source Money alone does not extend lives. UC Atlas of Global Inequality website. http://ucatlas.ucsc.edu/index.php. Accessed September 23, 2014.