Medical Technology and the Health Care System A Study of the Diffusion of Equipment-Embodied Technology (1979) / Chapter Skim
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APPENDIX B: A CASE STUDY OF MAMMOGRAPHY
APPENDIX B: A CASE STUDY OF MAMMOGRAPHY
Pages 101-123
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From page 101... ...
Sufficient data and experience are now available on the use of mamtnography in older women, so that a reasonably good evaluation can be made of its effectiveness and benefits. The evaluation methodology presented in this sutdy is that of cost-effectiveness, i.e., the comparison of the costs of alternative methods for achieving the specific objective of the detection of breast cancers.
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From page 102... ...
Purposes Generally, women seek advice from a physician when they discover a lump in the breast or have other breast symptoms, or they become anxious when they learn of someone else who has breast cancer. In the past decade, publicity by various media has motivated women to undertake periodic breast cancer screening by selfexamination and/or visits to cancer detection programs.
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From page 103... ...
, the normal increase in fatty tissue in the breast provides more contrast in the mammograms and improves the sensitivity and specificity of the test. This, plus the higher prevalence of breast cancer in older women, explains the greater cost-effectiveness of screening mammography for postmenopausal women as compared to premenopausal women.
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From page 104... ...
Since the mid-l960's, X-ray and thermography techniques for breast cancer detection have been increasingly used. In the l940's, about 63 percent of women with breast cancer had axillary node involvement at the time of diagnosis, in the l950's about 57 percent, and in the l960's about 50 percent.1 Since the mortality rate from breast cancer did not change in 40 years from clinical examination alone, it is evident that more sensitive methods for earlier detection of breast cancer are needed.
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From page 105... ...
Currently, public policy on screening mammography is being generally set by the National Cancer Institute and the American Cancer Society, and the results of their ongoing early Breast Cancer Detection Demonstration Projects will probably establish policy for the future.
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From page 106... ...
X-ray examinations of the breast are increasingly being used in breast cancer screening programs because mammography is a more sensitive test than clinical examination,
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From page 107... ...
Some breast cancer detection programs provide both a screening mammogram and a clinical examination of the breasts by physicians or trained nurses. Since there is less controversy in the screening of women over age 50 due to their relatively high rate of breast cancer, the lower risk of radiation-induced cancer, and the increased sensitivity of mammography in this age-group, this analysis will assume that four groups each of l0,000 women age 50 and older were randomly selected and three will be tested by one of the above modes and one group will serve as controls.
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From page 108... ...
The participants in the group in Figure 4 receive both screening mammograms and clinical examinations, for their initial and three annual reexaminations. The costs of any test mode could be decreased further by prescreening out women with lower than average risks of breast cancer (i.e., examining only those with certain types of benign breast disease, with early onset of menses, no pregnancies, with a family history of breast cancer, etc.)
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From page 109... ...
3. For each single screening examination, the sensitivity of the test made is such that clinical examination detects 60 percent of breast cancers, current mammography technology detects 85 percent (preliminary BCDDP data exceed 85 percent sensitivity )
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From page 110... ...
5-l0 5 Average screening cost for clinical examination l0 Mammography screening, bilateral (two views each breast) 5-62 20 Breast biopsy and associated workup for negative biopsy case 750-l,l50 930 (biopsy, anesthetic, operating room, frozen section, one hospital day at $l25)
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From page 111... ...
Of the 50 patients with axillary nodes involved, 25 will require subsequent care for cancer recurrence with additional chemotherapy and/or radiation therapy and an average of 2 weeks hospitalization over the 5 years for a cost ranging from $4,000 to $8,000, or for an average cost of $6,000 per case. Of the 50 patients without axillary node involvement, only 5 will have a recurrence of cancer and require similar late hospital care.
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From page 113... ...
The total projected costs for breast cancer care for this group of l0,000 women receiving annual breast clinical examinations are $l,573,5l0, or $l5,735 per cancer patient, or $l57 per examinee for the 5-year period. Figure 3 shows the predicted experience for the 5-year period for the group who receive only annual screening mammograms.
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From page 114... ...
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From page 117... ...
For both clinical examination and mammography, this would change from 95 percent for a single examination to 97 percent from four annual examinations. In other words, the least sensitive test, a single clinical examination in 5 years, will miss 30 breast cancers in l0,000 women; whereas the most sensitive testing alternative, annual clinical examinations and mammography, will miss only three breast cancers in 5 years in l0,000 women.
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From page 118... ...
The costs for care of patients with axillary node involvement and for late care for recurrent cancer are extremely variable since these are less standardized and will need to be individualized in accordance with the prevailing medical and surgical practice of each community. Based upon the assumptions presented in this study, for women age 50 or more with an expected 5-year rate of breast cancer of l00 per l0,000 or more, health care costs for 5 years from annual screening mammograms can be projected to be less costly than: (l)
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From page 119... ...
By this evaluation model, for women ages 35 to 50 years, the yield rates from screening mammography will be insufficient to make the procedure costeffective, since the prevalence of breast cancer is about onehalf that of women age 50 or greater and the sensitivity of mammography is less in premenopausal women (since there is less fatty tissue in the breast, which makes it more difficult to visualize early cancer)
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From page 120... ...
POLICY IMPLICATIONS Evaluations, such as described in the preceding section, carried out by large screening programs so as to provide their own data on costs and effectiveness will help to establish firm guidelines and policies for mammography in breast cancer detection and control. Especially necessary are more followup data on women age 35-50 who already have been exposed to periodic mammography, adjusting for the fact that with current technology (l)
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From page 121... ...
The increased benefits from earlier cancer detection in decreasing the numbers of late cases become paramount, since the study shows so little difference in 5-year costs. Therefore, it becomes advisable for policymakers to do a cost-benefit analysis and assign some values to the various increased benefits from screening mammography for women age 50 and over.
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From page 122... ...
"Changes in 5-Year Breast Cancer Mortality in a Breast Cancer Screening
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From page 123... ...
"Periodic Breast Cancer Screening in Reducing Mortality from Breast Cancer." Journal of the American Medical Association 2l5(l97l)
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