Taking a Value-Based Approach to Breast Cancer Screening, Workup, and Surveillance

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

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.⁴

Screening

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.⁸

Workup

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 and MONET¹⁰ 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.

It is critical that we understand the potential yield of the studies we order, and avoid overuse of diagnostic tests that are not only unlikely to be helpful, but may also add to cost, radiation exposure, and/or otherwise unnecessary downstream invasive procedures carrying their own risks.

The “Choosing Wisely” campaign has highlighted for oncologists sources of potential waste. One of the Top Five recommendations from the American Society of Clinical Oncology (ASCO) in 2012, for example, was “[to not] perform PET, CT, and radionuclide bone scans in staging of early breast cancer at low risk of metastasis.” Yet, perhaps due to defensive medicine concerns or anecdotal experience, many continue to order metastatic workups on patients with stage I and II disease.¹²

Surveillance

When one considers the growing number of survivors in this country, our surveillance practices become of significant interest. Again, ASCO recommends against testing with biomarkers or imaging for asymptomatic individuals treated for breast cancer with curative intent.¹²

Some have used the hyperbole of “money not being an issue” when it comes to cancer; “spare no expense.” I would argue, however, that one needs to consider the value for our healthcare dollar; this is not simply about costs, but also about outcomes.

Without concomitant improvements in outcomes to justify cost, one needs to question our zeal for healthcare spending. Healthcare expenditures in this country are not only unsustainable from a societal perspective, but also impair the quality of life for individual patients faced with the financial burden associated with cancer care.¹³

The imperative is therefore clear. We need to do better in terms of deriving value—that is, better outcomes at lower cost for our patients. A critical appraisal of how we screen, workup, and provide ongoing surveillance for our breast cancer patients may be a first step in this direction.

References

1. Garber S, Gates SM, Keeler EB, et al; Rand Corporation. Redirecting innovation in U.S. health care: options to decrease spending and increase value. Published 2014. http://www.rand.org/pubs/research_reports/RR308.html. Accessed September 23, 2014.
2. American Cancer Society. Cancer Facts & Figures 2014. Atlanta: American Cancer Society; 2014.
3. American Cancer Society. How many women get breast cancer? http://www.cancer.org/cancer/breastcancer/overviewguide/breast-cancer-overview-key-statistics. Updated January 31, 2014. Accessed September 23, 2014.
4. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008;27(3):759-769.
5. Miller AB, Wall C, Baines CJ, et al. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. 2014;348:g366.
6. Gross CP, Long JB, Ross JS, et al. The cost of breast cancer screening in the Medicare population. JAMA Intern Med. 2013;173(3):220-226.
7. Killelea BK, Long JB, Chagpar AB, et al. Evolution of breast cancer screening in the Medicare population: clinical and economic implications. J Natl Cancer Inst. 2014;106(8):dju159 doi: 10.1093/jnci/dju159.
8. Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med. 2012;367(21):1998-2005.
9. Turnbull L, Brown S, Harvey I, et al. Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial. Lancet. 2010;375(9714):563-571.
10. Peters NH, van Esser S, van den Bosch MA, et al. Preoperative MRI and surgical management in patients with nonpalpable breast cancer: the MONET-randomised controlled trial [published online December 30, 2010]. Eur J Cancer. 2011;47(6):879-886.
11. Houssami N, Turner R, Macaskill P, et al. An individual person data meta-analysis of preoperative magnetic resonance imaging and breast cancer recurrence [published online January 6, 2014]. J Clin Oncol. 2014;32(5):392-401.
12. Schnipper LE, Smith TJ, Raghavan D, et al. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology [published online April 3, 2012]. J Clin Oncol. 2012;30(14):1715-1724.
13. Fenn KM, Evans SB, McCorkle R, et al. impact of financial burden of cancer on survivors' quality of life [published online May 27, 2014]. J Oncol Pract. 2014;10(5):332-338.