The financial implications of investigating false-positive and true-positive mammograms in a national breast cancer screening program
Jason Soon
A * , Nehmat Houssami B C , Michelle Clemson D , Darren Lockie D , Rachel Farber B , Alexandra Barratt B , Adam Elshaug A E and Kirsten Howard A
A Menzies Centre for Health Policy and Economics, School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia.
B School of Public Health, Faculty of Medicine & Health, University of Sydney, NSW, Australia.
C Daffodil Centre, The University of Sydney – joint venture with Cancer Council NSW, NSW, Australia.
D Maroondah BreastScreen, Eastern Health, Vic., Australia.
E Centre for Health Policy, Melbourne School of Population and Global Health and the Melbourne Medical School, University of Melbourne, Vic., Australia.
Australian Health Review 47(2) 159-164 https://doi.org/10.1071/AH22120
Submitted: 13 May 2022 Accepted: 15 November 2022 Published: 8 December 2022
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Objectives To determine the total annual screening and further-investigation costs of investigating false-positive and true-positive mammograms in the Australian population breast-screening program.
Methods This economic analysis used aggregate-level retrospective cohort data of women screened at a breast-screening clinic. Counts and frequencies of each diagnostic workup-sequence recorded were scaled up to national figures and costed by estimating per-patient costs of procedures using screening clinic cost data. Main outcomes and measures estimated were percentage share of total annual screening and further-investigation costs for the Australian population breast-screening program of investigating false-positive and true-positive mammograms. Secondary outcomes determined were average costs of investigating each false-positive and true-positive mammogram. Sensitivity analyses involved recalculating results excluding subgroups of patients below and above the screening age range of 50–74 years.
Results Of 8235 patients, the median age was 60.35 years with interquartile range of 54.17–67.17 years. A total of 15.4% (ranging from 13.4 to 15.4% under different scenarios) of total annual screening and further-investigation costs were from investigating false-positive mammograms. This exceeded the share of costs from investigating true-positives (13%).
Conclusions We have developed a transparent and non-onerous approach for estimating the costs of false-positive and true-positive mammograms associated with the national breast-screening program. While determining an optimal balance between false-positives and true-positive rates must rely primarily on health outcomes, costs are an important consideration. We recommend that future research adopts and refines similar approaches to facilitate better monitoring of these costs, benchmark against estimates from other screening programs, and support optimal policy development.
Keywords: breast cancer, breast neoplasms, BreastScreen Australia, cancer screening, cost of healthcare, digital breast tomosynthesis, false-positive results, health services, mammography, public health, women’s health.
References
[1] Roder D, Houssami N, Farshid G, et al. Population screening and intensity of screening are associated with reduced breast cancer mortality: evidence of efficacy of mammography screening in Australia. Breast Cancer Res Treat 2008; 108 409–416.| Population screening and intensity of screening are associated with reduced breast cancer mortality: evidence of efficacy of mammography screening in Australia.Crossref | GoogleScholarGoogle Scholar |
[2] Department of Health and Ageing. BreastScreen Australia Evaluation. Screening monograph no. 4/2009. Canberra: Department of Health and Ageing; 2009.
[3] Lerman C, Track B, Rimer BK, Boyce A, Jepson C, Engstrom PF. Psychological and behavioral implications of abnormal mammograms. Ann Intern Med 1991; 114 657–661.
| Psychological and behavioral implications of abnormal mammograms.Crossref | GoogleScholarGoogle Scholar |
[4] Gram I, Lund E, Slenker S. Quality of life following a false positive mammogram. Br J Cancer 1990; 62 1018–1022.
| Quality of life following a false positive mammogram.Crossref | GoogleScholarGoogle Scholar |
[5] Swanson V, McIntosh IB, Power KG, Dobson H. The psychological effects of breast screening in terms of patients’ perceived health anxieties. Br J Clin Pract 1996; 50 129–135.
[6] Hofvind S, Ponti A, Patnick J, et al. False-positive results in mammographic screening for breast cancer in Europe: a literature review and survey of service screening programmes. J Med Screen 2012; 19 57–66.
| False-positive results in mammographic screening for breast cancer in Europe: a literature review and survey of service screening programmes.Crossref | GoogleScholarGoogle Scholar |
[7] Lehman CD, Arao RF, Sprague BL, et al. National Performance Benchmarks for Modern Screening Digital Mammography: Update from the Breast Cancer Surveillance Consortium. Radiology 2017; 283 49–58.
| National Performance Benchmarks for Modern Screening Digital Mammography: Update from the Breast Cancer Surveillance Consortium.Crossref | GoogleScholarGoogle Scholar |
[8] Ho TH, Bissell MCS, Kerlikowske K, et al. Cumulative Probability of False-Positive Results After 10 Years of Screening With Digital Breast Tomosynthesis vs Digital Mammography. JAMA Netw Open 2022; 5 e222440
| Cumulative Probability of False-Positive Results After 10 Years of Screening With Digital Breast Tomosynthesis vs Digital Mammography.Crossref | GoogleScholarGoogle Scholar |
[9] Lidbrink E, Elfving J, Frisell J, Jonsson E. Neglected aspects of false positive findings of mammography in breast cancer screening: analysis of false positive cases from the Stockholm trial. BMJ 1996; 312 273–276.
| Neglected aspects of false positive findings of mammography in breast cancer screening: analysis of false positive cases from the Stockholm trial.Crossref | GoogleScholarGoogle Scholar |
[10] Chubak J, Boudreau DM, Fishman PA, Elmore JG. Cost of breast-related care in the year following false positive screening mammograms. Med Care 2010; 48 815–820.
| Cost of breast-related care in the year following false positive screening mammograms.Crossref | GoogleScholarGoogle Scholar |
[11] Ong MS, Mandl KD. National expenditure for false-positive mammograms and breast cancer overdiagnoses estimated at $4 billion a year. Health Aff 2015; 34 576–583.
| National expenditure for false-positive mammograms and breast cancer overdiagnoses estimated at $4 billion a year.Crossref | GoogleScholarGoogle Scholar |
[12] Australian Bureau of Statistics. 3101.0 National, state and territory population, September 2020, Table 4. 2022. Available at https://www.abs.gov.au/statistics/people/population/national-state-and-territory-population/latest-release#data-download [accessed 11 May 2021].
[13] BreastScreen Australia. National Accreditation Standards, Information for clinical staff. 2019. https://www.health.gov.au/sites/default/files/documents/2019/09/breastscreen-australia-national-accreditation-standards-nas-breastscreen-australia-national-accreditation-standards.pdf [accessed 14 June 2021].
[14] Saxby K, Nickson C, Mann GB, et al. The financial impact of a breast cancer detected within and outside of screening: lessons from the Australian Lifepool cohort. Aust N Z J Public Health 2020; 44 219–226.
| The financial impact of a breast cancer detected within and outside of screening: lessons from the Australian Lifepool cohort.Crossref | GoogleScholarGoogle Scholar |
[15] Australian Institute of Health and Welfare. Analysis of breast cancer outcomes and screening behaviour for BreastScreen Australia. Cancer series no. 113. Cat. no. CAN 118. Canberra: AIHW; 2018.
