Understanding which women do or don't undergo breast screening mammography — and why — is key to increasing screening utilization rates in the U.S. But the cost of screening may not play as big a role as was once thought, according to research presented at a Sunday session.
"Breast cancer is the most commonly diagnosed cancer among women in the U.S. and the second leading cause of cancer deaths," said researcher Soudabeh Fazeli Dehkordy, MD, MPH, a radiology resident at the University of California, San Diego. "But disparities in breast cancer screening and outcomes still persist among vulnerable populations."
The presentation focused on how two major policy changes in the U.S. over the last decade – the passage of the Affordable Care Act (ACA) and the release of revised United States Preventive Services Task Force (USPSTF) guidelines — have impacted screening rates for people of different races and income levels.
Passed in 2010, the ACA mandated full coverage of preventive services, including screening for breast cancer. While annual screening with mammography for women has historically recommended beginning at age 40, in 2009, the USPSTF announced a controversial new recommendation for biennial screening for women between the ages of 50 and 74.
Researchers used patient-level analytic files between 2004 and 2014 from Optum™ Clinformatics™ Data Mart, including women 40-74 years old with no history of breast cancer or mastectomy and with at least one year of continuous enrollment in a given insurance plan. The team examined out-of-pocket payments and utilization for screening mammography by race and income level. An average of 1,763,959 women were included in the study each year.
The team then calculated the slopes and compared trends before and after 2009 and 2010 to assess the impact of the implementation of the ACA and USPSTF guideline revisions on screening mammography cost sharing elimination and utilization.
The study found that cost-sharing elimination had already been on the rise in the U.S. before it was mandated by the ACA with more than 90 percent of women of all races and income groups having access to mammograms at no cost. As the law was implemented, Dr. Dehkordy said researchers saw a small, but statistically significant upward trend in cost-sharing eliminated across all groups as the procedure became accessible for all.
Essentially, the rates for cost-share elimination were already very high before ACA, and continued to rise after it was implemented.
Researchers Seek New Ways to Encourage Screening
In terms of utilization, researchers saw a small upward trend in the data from 2004 to 2007, but then saw rates plateau or decline among nearly all race and income groups after 2009, when the new USPSTF guidelines were announced. This decline occurred despite the elimination in cost-sharing that was now widely implemented because of ACA, researchers said.
The only exception to those downward utilization trends was among African American women, who traditionally have higher breast cancer mortality rates than other races. Greater education, or other factors aside from the cost-share elimination, may be at play. "The racial gap in screening mammography may be closing among African Americans," Dr. Dehkordy said.
"Eliminating out of pocket costs is helpful, but it doesn't seem to be enough, so we have to think of other ways to encourage women to undergo screening mammography or facilitate ways for them to get screened," Dr. Dehkordy said.
Because there are many reasons why women don't undergo screening mammography, including some factors not included in this study, continued research on the topic is critical.