每2年乳房X线检查安全且可省数十亿美元

根据《内科学年鉴》2月3日发表的研究结果，如果完全遵循美国预防服务工作组(USPSTF)乳房X线筛查指南，可以在不牺牲诊疗质量的情况下每年节省大约44亿美元。



如果将乳房X线检查、计算机辅助检测、回访、活检的费用及其他变量纳入考虑范围，据研究者估算，假如2010年符合USPSTF标准的女性85%接受筛查(对年龄50~74岁的女性、年龄40~49岁的高危女性，以及年龄75~85岁且共病很少的女性每2年筛查1次)，可节省35亿美元(Ann. Intern. Med. 2014 Feb. 3;160:145-53 [doi:10.7326/M13-1217])。

然而，由于美国人尚不确定最佳筛查策略，因此2010年有70%的女性采用了不同筛查方案，实际花费了78亿美元。假如按照美国癌症学会(ACS)等学术组织的建议，年龄40~84岁女性每年筛查1次，且筛查率达到85%，则2010年的筛查费用将高达101亿美元。因此，在筛查率为85%的情况下，年龄50~69岁的女性按照欧洲策略每2年筛查1次，即可节省26亿美元。

美国伊利诺伊大学的Cristina O’Donoghue医生及其同事指出，既往研究已发现，每2年筛查1次的假阳性和回访更少，而晚期癌症检出率并不显著增加。“遵循基于最佳证据的指南——例如USPSTF指南——进行乳房X线筛查，有助于改进筛查工作和节省大量成本。应当将钱花在更有价值的地方，包括提高乳房X线筛查的可及性、增加基于风险的筛查、乳腺癌预防，以及由经验丰富、差错率低的专家阅片等。然而，在美国要想降低筛查频率仍有不小的阻力。”


Cristina O’Donoghue医生

研究者总结称，乳房X线筛查的费用主要取决于筛查频率，其次是接受筛查的女性所占百分比、每次筛查的费用、接受数字化乳房X线筛查的女性所占百分比，以及乳房X线筛查后回访的百分比。

研究者声称无相关利益冲突。这项研究获得了加州大学和Safeway基金会的资助。

随刊述评：将筛查费用纳入讨论范围

我们对O’Donoghue医生及其同事细致评估美国乳腺癌筛查总费用的工作表示赞赏。尽管人们常常对模拟模型得出的假设结果怀有疑虑，但O’Donoghue医生等人的文章是合乎情理且相对保守的(Ann. Intern. Med. 2014 Feb. 3;160:203-4)。

将费用纳入癌症筛查讨论具有挑战性。不仅医生和患者都不太清楚费用信息，而且还有人担心单纯谈论费用会妨碍医疗资源的分配。然而，对持赞成观点和怀疑观点的人都应当了解不同乳腺癌筛查策略的相关费用，尤其是在对哪种方式最有效的问题争议颇多的情况下。

费用应当成为讨论的一部分，因为购买了高自负额健保计划的女性可能会发现辅助影像学检查和操作给自己带来了较大经济负担。在社会层面上，应当将费用纳入有关筛查的政策讨论中。不同乳腺癌筛查策略之间多达近80亿美元的费用差异，差不多是美国国立癌症研究所(NCI)年预算额的2倍。

述评作者：华盛顿大学内科学教授Joann Elmore博士，耶鲁大学内科学教授Cary Gross博士。Gross博士是Fair Health公司的委员会成员，并承认获得了美敦力和21世纪肿瘤学提供的津贴。

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By: M. ALEXANDER OTTO, Internal Medicine News Digital Network

Following United States Preventive Services Task Force mammography screening guidelines would save about $4.4 billion annually, without sacrificing quality of care, according to a study published online Feb. 3 in the Annals of Internal Medicine.

Taking the costs of mammography, computer-aided detection, recalls, biopsies, and other variables into account, the investigators estimated that it would have cost $3.5 billion to screen 85% of women in 2010 who met the USPSTF criteria: Screen women aged 50-74 years every other year, plus high-risk women aged 40-49 years and women aged 75-85 years with few comorbidities biennially (Ann. Intern. Med. 2014 Feb. 3;160:145-53 [doi:10.7326/M13-1217]).

Instead, $7.8 billion was actually spent in 2010 to screen just 70% of women using the mélange of screening practices in place today in the United States, a byproduct of the country’s uncertainty about the right way to proceed, the researchers noted.

Meanwhile, following the advice of the American Cancer Society and other groups for annual screenings of women aged 40-84 years would have cost $10.1 billion if 85% had come into the clinic. Screening 85% of women aged 50-69 years biennially – in keeping with the European approach – would have cost $2.6 billion.

Previous studies have found fewer false-positives and recalls with biennial screening, and no significant increase in late-stage cancer detections, said Dr. Cristina O’Donoghue of the University of Illinois at Chicago and her associates.

"Following mammography screening guidelines, such as those from the USPSTF, [which] optimize frequency on the basis of best-available evidence will ... improve screening and save billions of dollars," money that’s better spent on expanding mammography access and increasing risk-based screening, breast-cancer prevention, and mammography reading by experts less likely to make mistakes, among other things, the researchers said.
 
Even so, "in the United States, there has been resistance to reducing frequency or modifying the age-range for mammography. Those who advocate annual screening should justify the increased costs of nearly $7 billion per year, compared with biennial policies," they said.

The project was a modeling exercise to price out various approaches to breast cancer screening using Medicare reimbursement rates; census figures; Breast Cancer Surveillance Consortium records; and other data sources. The researchers stated that they thought the cost information would help doctors, women, and policy makers find the right approach, especially as the Affordable Care Act improves mammography access and increases screening rates.

The U.S. task force’s biennial approach "is in line with our national goals of advancing health care delivery while improving cost-efficiency," the researchers said.

They concluded that screening frequency is the main driver of costs in mammography, followed by the percentage of women screened, cost per screen, percentage of women screened with digital mammography, and percentage of mammography recalls.

The researchers had no financial conflicts to disclose. The study was funded by the University of California and the Safeway Foundation.

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Make screening costs part of the conversation

We applaud [Dr.] O’Donoghue and [her] colleagues for meticulously assessing the total cost of breast cancer screening in the United States. Although there is often cause to be skeptical about simulation models because results are based on numerous assumptions, we find the article by O’Donoghue and colleagues to be reasonable and conservative.

Integrating cost into the cancer screening conversation is a challenge. Providers and patients are not only shielded from cost information, but some may raise concerns that the mere mention of costs is a step down the road to rationing. However, both advocates and skeptics should know the costs associated with different breast-cancer screening strategies, particularly when there is so much debate about which approach is most effective.

Costs, including out-of-pocket costs, should be part of the conversation because women with high-deductible health plans may find themselves facing a hefty bill for adjunctive imaging tests and procedures. At the societal level, costs should be integrated into our national dialogue about screening. It is unsustainable to remain ignorant of the costs associated with any health intervention, even breast-cancer screening.

The approximate $8 billion difference among breast-cancer screening strategies is roughly twice as large as the entire annual budget of the National Cancer Institute.

Dr. Joann Elmore and Dr. Cary Gross made the above comments in an editorial accompanying the study (Ann. Intern. Med. 2014 Feb. 3;160:203-4). Dr. Elmore is a professor of medicine at the University of Washington in Seattle. Dr. Gross is a professor of medicine at Yale University in New Haven, Conn., and director of the school’s Cancer Outcomes Public Policy and Effectiveness Research Center. Dr. Gross is a paid Fair Health Inc. board member and disclosed grants from Medtronic and 21st Century Oncology.