BREAST CANCER (Screening)

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 8/09/2011


Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation
The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.

Evidence Rating: B (Recommended/At Least Fair Evidence)
There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for women aged 40 to 49 years. The strongest evidence for the greatest benefit is among women aged 60 to 69 years.

NOTE:
  • The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
    Grade: C recommendation.
  • The USPSTF recommends against teaching breast self-examination (BSE). Grade: D recommendation.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement.




The Value of Prevention

Economic Burden of Condition/Disease
The direct medical care costs for breast cancer treatment were estimated to exceed $6 billion in 1996.8 The total economic burden of breast cancer would be much higher if breast cancer related mortality and morbidity costs were included in this figure. In 2004, for example, the overall cost of cancer (including direct and indirect cots) was estimated to be almost $190 billion9, and breast cancer could account for up to one-quarter of this total.10 A small proportion of the economic burden of breast cancer is attributable to genetically-related breast cancers.

The risk of breast cancer increases with age.7 Population aging in the coming decades is expected to increase the number of breast cancer cases and the economic burden of the disease.

Workplace Burden of Condition/Disease
Women aged 40 to 64 years accounted for 61% of in situ cases, 54% of invasive breast cancer cases, and 40% of breast cancer deaths in 2005.2 The breast cancer medical care costs, productivity losses, and mortality costs among working women in this group is substantial.

Economic Benefit of Preventive Intervention Screening
Screening may reduce breast cancer treatment costs by identifying tumors in their earliest stages when treatment is more successful and less expensive. For example, a study that examined the cancer-care costs among members of a health maintenance organization (HMO) found that the net cost of initial care for breast cancer was $7,093 when the cancer was identified at the carcinoma in situ stage and to $10,900 when it was identified at the regional stage (both figures in year 1992 dollars).up>11

Estimated Cost of Preventive Intervention Screening
In 2004, the private-sector cost of a screening mammography averaged $51 (range $0 to $122).12 A diagnosis of breast cancer is more costly ($451 to $2,520 in year 2002 dollars) as it requires additional tests, interpretations, and office visits.7

Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention Screening
The cost-effectiveness of breast cancer screening depends on the age of the population screened. Many cost-effectiveness analyses have shown that screening for breast cancer in women 65 years of age and younger reduces mortality at a reasonable cost.1 A systematic review of cost-effectiveness analyses performed for the USPSTF noted that biennial screening after the age of 65 also reduces mortality at a reasonable cost. However, screening becomes more costly in women with significant comorbidities, such as dementia, or comorbidities that limit life expectancy. For example, the incremental costs per life-year saved for screening beyond age 65 were found to range from $34,000 to $88,000 in year 2002 dollars4, which compare favorably with most other preventive interventions and to commonly accepted cost-effectiveness benchmarks.2



Condition / Disease Specific Information

Epidemiology of Condition/Disease
Breast cancer is the most commonly diagnosed non-skin cancer and the second leading cause of cancer death among women in the United States.2 In 2005, 211,000 women are expected to be diagnosed with breast cancer and 40,000 women are expected to die as a result of breast cancer.2

Condition/Disease Risk Factors
Risk factors for breast cancer (reported by the USPSTF) include:3
  • A family history of breast cancer (especially a mother or sister with breast cancer)
  • Atypical hyperplasia
  • Having a first child after the age of 30
  • Increasing age
Risk factors reported by other organizations include:4-6
  • Early age at menarche
  • Late age at menopause
  • Overweight/obesity
  • Physical inactivity
  • Hormone replacement therapy
  • Exposure to radiation
Another risk factor for breast cancer is the presence of genetic markers for the BRCA1 or BRCA2 genes.6 However, only a small proportion of breast cancer cases are attributable to genetic susceptibility. Approximately 2% of adult women in the United States have a family history indicating they are at increased risk of a deleterious mutation in the BRCA1 or BRCA2 gene, and about 1 in 10 women with these histories (2 to 3 per 1,000 adult US women) actually have a mutation.7 Among women with a deleterious BRCA1 or BRCA2 mutation, 35% to 84% may develop breast cancer by age 70.7


Preventive Intervention Information

Preventive Intervention: Purpose of Screening
Mammography screening is a valuable early detection tool because it can identify breast cancer at an early stage, usually before physical symptoms or complications develop, and when treatment is more effective and less expensive.

Benefits and Risks of Intervention Screening
Screening allows for the early detection of breast cancer. Screening is estimated to reduce breast cancer mortality by 20% to 25% during the 10-year period following screening.1 The risk of breast cancer increases with age. Therefore, the absolute benefit of screening also increases as a woman ages, at least from age 40 through age 70.3 Because the risk of breast cancer is higher after age 70, mammography may offer important benefits to older women. However, these benefits may be offset by the fact that many older women, especially the very old and those with other illnesses, will die from other causes before they experience the benefits of early cancer detection.3 Risks associated with screening include false-positive test results, which may cause undue anxiety, and the inconvenience, occasional complications, and costs associated with biopsies. False-positive test results are common among all types of cancer screening, including mammography; 80% to 90% of abnormal mammogram or clinical breast exam results are false-positive.3

Initiation, Cessation and Interval Screening
According to the USPSTF women aged 40 and above should be screened for breast cancer with mammography, with or without CBE (clinical breast examination), every 1 to 2 years.3 The USPSTF notes that the precise age is not known when the benefits of breast cancer screening first outweigh the associated risks and costs; thus, the specific ages at which screening should begin and cease should consider patient preferences.3

Intervention Process: Screening
Approved screening methods for breast cancer include mammography and, as an adjunct, a clinical breast exam. CBE is a low-cost screening method that provides an opportunity for health professionals to discuss breast health with women.13 Although CBE is not explicitly recommended by the USPSTF, many experts encourage routine CBE.13

However, clinicians who perform routine CBE should understand that there is currently insufficient evidence to determine whether CBE affects breast cancer mortality and that they are likely to increase the incidence of clinical assessments and biopsies.3 Coverage should also include diagnostic follow-up. Coverage should also include diagnostic follow-up (e.g., biopsies).

Treatment Information
Health benefits should include provisions for diagnostic and treatment services.



Strength of Evidence for the Clinical Preventive Service Breast Cancer (Screening)

The level of evidence supporting the recommendations contained in this section is described below.
Evidence-Based Research:
U.S. Preventive Services Task Force (USPSTF)
Strength of Evidence: B (Recommended/At Least Fair Evidence)
  • The USPSTF found fair evidence to recommend screening mammography, with or without clinical breast examination (CBE), every 1 to 2 years for women aged 40 and older.1


Summary Plan Description

Summary Plan Description Language: Breast Cancer (Screening)

Covered Screening
Breast cancer screening is a covered benefit and may include mammography and, as an adjunct, a clinical breast exam (CBE).

Initiation, Cessation, and Interval
Breast cancer screening is a covered benefit for average-risk women aged 40 to 80. Average-risk women are eligible for one mammography per calendar year. Women at high risk of breast cancer may qualify for screening at a younger age, if screening is deemed medically indicated.

CPT Codes

Breast Cancer (Screening)
77057 Screening mammography, bilateral
77052 Computer aided detection with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography
76499 Electrical impedance scan of the breast, bilateral (risk assessment device for breast cancer)
99386 Initial preventive medicine evaluation and management, 40 to 64 years, new patient
99387 Initial preventive medicine evaluation and management, 65 years and older
99396 Periodic preventive medicine evaluation and management, 40 to 64 years, established patient
99397 Periodic preventive medicine evaluation and management, 65 years and older
S8075* Computer analysis of full-field digital mammogram and further physician review and interpretation, mammography



Other Information and Resources

Business Group Resource(s)

CDC Resource



Author(s)

Campbell KP, Coates RJ, Lanza A, Chattopadhyay S. Breast cancer evidence-statement: screening, counseling, testing, preventive medication, and preventive treatment. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006.

References

1 U.S. Preventive Services Task Force. Screening for breast cancer. AHRQ Publication No. APPIP02-0016. Rockville (MD): Agency for Health Care Research and Quality; 2002.
2 American Cancer Society. Breast cancer facts & figures 2005-2006. Atlanta, GA: American Cancer Society, Inc.; 2005.
3 Berg AO, Atkins D. Screening for breast cancer: recommendation and rationale. Ann Intern Med. 2002;137(5 Part 1):344-6.
4 International Agency for Research on Cancer. Weight control and physical activity. IARC Handbooks of cancer prevention. Vol. 6. Lyon: IARC Press; 2002.
5 Curry SJ, Byers T, Hewitt M, editors. Fulfilling the potential of cancer prevention and Early detection. Washington, DC: National Academies Press; 2003.
6 National Cancer Institute. Breast cancer PDQ treatment. General information about breast cancer. Available at: http://www.nci.nih.gov/cancertopics/pdq/treatment/breast/patient/. Accessed May 21, 2009.
7 Nelson HD, Hoyt Huffman L, Fu R, Harris EL. Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2005;143:362-7.
8 Brown ML, Lipscomb J, Snyder C. The burden of illness of cancer: economic cost and quality of life. Annu Rev Public Health. 2001;22:91-113.
9 American Cancer Society. Cancer facts & figures 2005. Atlanta, GA: American Cancer Society; 2005.
10 Radice D, Redaelli A. Breast cancer management: quality of life and cost considerations. Pharmacoeconomics. 2003;21:383-96.
11 Taplin SH, Barlow W, Urban N, Mandelson MT, Timlin DJ, Ichikawa L, et al. Stage, age, comorbidity, and direct costs of colon, prostate, and breast cancer care. Journal of the National Cancer Institute. 1995;87(6):417-426.
12 Thomson Reuters. 2004 MarketScan® Commercial Commercial Claims and Encounters Database. 2005.
13 Saslow D, Hannan J, Osuch J, Alciati MH, Baines C, Barton M, et al. Clinical breast examination: practical recommendations for optimizing performance and reporting. CA Cancer J Clin. 2004;54:327-44.