Use and Costs of Breast Cancer Screening for Women in Their 40s in a US Population With Private Insurance

Abstract

This study uses Blue Cross Blue Shield Axis data to examine the total annual cost of breast cancer screening for women aged 40 through 49 years in the United States.

Although professional society guidelines vary, most private insurance companies in the US will reimburse for the costs of mammography for women age 40 through 49 years.¹ While the clinical benefits and harms of screening women in their 40s have been widely discussed,^2,3 there is limited evidence regarding the cost implications of contemporary breast cancer–screening practices among this population. We estimated annual breast cancer screening–associated costs among US women in their 40s who have private insurance. We also assessed regional variation in these costs.

Methods

We conducted a retrospective study of women aged 40 through 49 years who had private insurance using data from the Blue Cross Blue Shield Axis, a large commercial claims database accessed via a secure portal. We selected women between ages 40 and 49 years who were eligible to receive a screening mammography in 2017 and identified screening mammography in 2017 using a validated algorithm and relevant Current Procedural Terminology codes.⁴ For each beneficiary screened, we identified subsequent evaluation tests in the 4 months after the initial screening mammography and calculated the total annual cost of screening based on use and unit costs of initial screening (2-dimensional mammography with or without digital breast tomosynthesis [DBT]), supplementary screening (screening ultrasonography), recall (diagnostic 2-dimensional mammography with or without DBT and ultrasonography), and other diagnostic tests (magnetic resonance imaging and biopsy). We then estimated the mean cost per beneficiary screened.

To estimate national screening costs, using a previously applied approach,⁵ we multiplied the total national number of women with private insurance who were aged 40 through 49 years and eligible for breast cancer screening by the proportion of women screened and the mean per-beneficiary-screened cost of screening derived from our study. To examine regional variation, we estimated the mean total per-beneficiary-screened cost for each hospital referral region (HRR), and evaluated variation in these estimates across HRRs (eAppendix in the Supplement). The Human Investigation Committee of Yale School of Medicine approved this study as exempt (in a category for research with deidentified secondary data); thus, informed consent was not needed. Analyses were performed using SQL Server Management Studio version 17.0 (Microsoft), STATA/MP version 14.1 (StataCorp), and R version 3.5.3 (R Foundation for Statistical Computing).

Results

Our study cohort included 2 257 393 women aged 40 to 49 years. Of these women, 930 526 (41.2%) were screened with mammography in 2017, 543 380 (24.1%) with 2-dimensional mammography, and 387 146 (17.2%) with DBT (Table). Among the 930 526 women who had a screening mammography during the study period (either with or without DBT), 137 764 (14.8%) were recalled for diagnostic evaluation and 20 229 (2.2%) were referred for other diagnostic tests (Table).

Table. Annual Breast Cancer Screening Cost and Use Among Women in Their 40s With Private Insurance.

Screening-associated procedures	Screening cost, $			Use, No. (%)b
	Cost per beneficiary screened		Total national cost, $ millionsa
	Mean (SD)	Median (IQR)
Screening mammography
Total	249 (125)	226 (164-312)	1498	930 526 (41.2)
2-Dimensional	125 (133)	120 (0-213)	750	543 380 (24.1)
Screening digital breast tomosynthesisc	124 (170)	0 (0-250)	749	387 146 (17.2)
Supplementary screening ultrasonography	3 (35)	0 (0-0)	21	12 607 (1.4)
Recall
Total	56 (172)	0 (0-0)	337	137 764 (14.8)
Diagnostic 2-dimensional mammography	21 (81)	0 (0-0)	125	79 064 (8.5)
Diagnostic digital breast tomosynthesisc	8 (56)	0 (0-0)	47	22 388 (2.4)
Diagnostic ultrasonography	27 (100)	0 (0-0)	165	103 388 (11.1)
Other diagnostic tests
Total	45 (421)	0 (0-0)	273	20 229 (2.2)
Biopsy	39 (375)	0 (0-0)	234	18 085 (1.9)
Magnetic resonance imaging	6 (118)	0 (0-0)	39	4434 (0.5)
Total screening and subsequent evaluationd	353 (539)	250 (174-367)	2128	NA

Abbreviations: IQR, interquartile range; NA, not applicable.

^aThe number of beneficiaries was calculated based on the total number of women with private insurance aged 40 to 49 years nationally using data from the US Census Bureau, excluding women diagnosed with breast cancer in 2012 through 2016, based on US Centers for Disease Control and Prevention data; the proportion of women aged 40 to 49 years with private insurance was based on health insurance coverage data from the National Center for Health Statistics, and the proportion of women aged 40 to 49 years receiving screening in contemporary practice was based on Blue Cross Blue Shield data set (details in the eAppendix in the Supplement).

^bUse in women who received mammography screening between January and December 2017.

^cDigital breast tomosynthesis includes 2-dimensional mammography.

^dTotal screening and subsequent evaluation consist of initial screening, supplementary screening, recall, and other diagnostic procedures.

The mean cost of breast cancer screening was $353 per beneficiary screened (Table). The main contributor to this mean (SD) cost was initial screening mammography (mean [SD] per-person cost, $249 [$125]) followed by recall (mean [SD] per-person cost, $56 [$172]) and other diagnostic tests (mean [SD] per-person cost, $45 [$421]). The median cost of breast cancer screening was $250 (interquartile range, $174-367) per beneficiary screened (Table). When extrapolating these costs to the population who have private insurance in the US, the total national cost of screening women in their 40s was $2.13 billion per year, most of which was accounted for by the initial screening mammography ($1.50 billion; Table).

There was substantial regional variation in breast cancer screening costs. The total annual mean (SD) costs of breast cancer screening varied from $151 ($258) to $751 ($1100) per beneficiary screened across HRRs (Figure).

Figure. Regional Hospital Referral Region–Level Mean Breast Cancer Screening Costs per Beneficiary Screened (N = 306).

The gray areas have not been assigned to any hospital referral regions (HRRs) based on the HRR definition used by the Dartmouth Atlas (https://www.dartmouthatlas.org/downloads/atlases/96Atlas.pdf).

Discussion

We found that although fewer than half of the women aged 40 through 49 years who had private insurance and were eligible received annual breast cancer screening in 2017, the estimated annual national cost was $2.13 billion. These costs are borne despite the unclear tradeoff between clinical benefits and risks of screening women aged 40 through 49 years. Furthermore, the cost per beneficiary screened varied 5-fold across regions. Of note, the costs identified in this study were substantially higher than estimates used in previous cost analyses (eg, 2-dimensional mammography unit cost: $213 in this study, compared with $140-$155 in prior studies).^5,6 Our data add clarity around the costs of breast cancer screening for women in their 40s, drivers of these costs, and magnitude of regional variation. They can help inform policy-makers’ decisions and future cost-effectiveness evaluations to optimize resource allocation.

Supplement.

eAppendix. Supplementary Methods.