[February 27, 2014]

New Study: Wide Variations in Breast Cancer Screening Follow-on Diagnostic Testing Raise Interesting Questions for Patients and Payers Alike

Spurred by provisions of the Affordable Care Act (ACA) and other legislation, usage of breast cancer screening mammography and related follow-on diagnostic testing is expected to increase in the coming years. Yet there is wide variation in the utilization and sequence of follow-on testing on a patient-by-patient basis, including a high rate of "false positive" for biopsies (the portion of biopsies for which cancer is not detected), which suggests that better methods for selecting suspicious lesions could reduce the number of unnecessary biopsies. Efforts by payers to ensure high quality and efficient care during the screening mammogram process should therefore extend to the tests used when those mammograms return suspicious results. This is according to a new study released today that analyzes commercial claims data, prepared by Milliman, Inc. and sponsored by Gamma Medica.

In the analysis, Milliman, a premier global consulting and actuarial firm, reviewed claims data from 2009-2011 from MarketScan®, a database of all paid claims generated by approximately 30 million commercially insured lives from roughly 100 private sector payers. They identified a study population of roughly one million women aged 30-64 screened by mammogram. They found 17% of screening mammograms had follow-on testing, a recall rate higher than the 5-14% rates that have been reported in other studies. Follow-on testing can include further mammograms, sonography, magnetic resonance imaging (MRI), molecular breast imaging (MBI), and biopsy, among other procedures.

Study authors determined the average breast cancer screening episode cost per 30-64 year old screened woman was $249.70, with the screening mammogram itself contributing 62% of the cost and the remaining 38% of the cost coming from follow-on diagnostics. Among follow-on diagnostics, nearly 18% of the total breast cancer screening episode cost was from biopsy, 8.3% from sonogram, 7.2% from follow-up diagnostic mammogram, and 4.2% from MRI. Less than 1% of the total cost was attributed to molecular breast imaging and other radiological imaging procedures.

The analysis noted wide variation in the utilization and sequencing of follow-on diagnostics. For example, some women had a single follow-on diagnostic ollowed by biopsy, while others received as many as four procedures with or without biopsy. Authors reported a breast biopsy rate (2.4%) from the study population twice as high as rates published by the Breast Cancer Surveillance Consortium, which collects screening data on more than 2 million U.S. women. The report also suggested a "false positive rate" (the portion of biopsies that do not find breast cancer) of 81%, higher than the 66-72% that has been reported by the Breast Cancer Surveillance Consortium. That rate didn't vary appreciably by the diagnostics that preceded the biopsy.

The findings come at a time of transformation for the breast cancer screening landscape: adherence is expected to increase due to the ACA's elimination of patient cost sharing, as well as a growing focus on the higher cancer risk facing women with dense breasts -- an estimated 40% of women for whom mammograms are not as sensitive in detecting cancer. At the same time, the breast cancer screening continuum is expensive, with wide variation in the utilization of the follow-on diagnostics that encompass a significant portion of screening costs. These findings highlight the need for payers/employers to evaluate the quality and value of breast cancer screening follow-on diagnostic patterns. In order to examine the quality and value of breast cancer screening follow-on diagnostic testing, payers/employers can review their population's breast cancer screening recall rates, biopsy rates, and evidence of subsequent cancer detection. A review of benefit coverage policies that align with emerging best practices in light of new evidence and technologies is also recommended. See the study for payer/employer considerations.

"Emerging technologies, including our own molecular breast imaging, have the potential to increase efficiency and improve the patient experience through high specificity, high sensitivity imaging that may reduce the number of unnecessary biopsies performed each year and reduce costs as a result," said Jim Calandra, President and Chief Executive Officer of Gamma Medica, which sponsored the report. "It's our hope that payers will review the study and consider efforts to improve the screening process for patients, and also to increase efficiencies."

To read the complete study, An Actuarial Analysis of Utilization and Cost of Breast Cancer Screening and Follow-on Diagnostics in a Commercially Insured Population, email [email protected] or visit this address:

http://us.milliman.com/insight/2014/An-actuarial-analysis-of-breast-cancer-screening-and-follow-on-diagnostics-in-a-commercially-insured-population/

About Gamma Medica, Inc.

Gamma Medica, Inc. is dedicated to the development of advanced digital imaging technologies that address the growing importance of overcoming the critical shortcomings of mammography and other screening modalities in the early detection of breast cancer. The company designs, builds and services the LumaGEM® MBI system, the first commercially available, FDA-cleared planar, dual head, fully solid-state digital imaging system utilizing cadmium zinc telluride (CZT) technology for molecular breast imaging. For more information, visit www.gammamedica.com.

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