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A rational expansion of breast cancer screening

In the ninth part of our series Health Rationing, Stephen Duckett examines the government’s decision to extend the breast cancer screening program. As one of many pre-budget teasers, Health Minister Plibersek…

Based on current evidence, expanding these services is the right thing to do. Image from shutterstock.com

In the ninth part of our series Health Rationing, Stephen Duckett examines the government’s decision to extend the breast cancer screening program.


As one of many pre-budget teasers, Health Minister Plibersek announced on Mother’s Day that Australia’s breast screening program will be extended to target women aged 50 to 74 instead of the current age range of 50 to 69.

There may be political benefits from this A$55 million spend, but is it a good deal?

From an economic rationality point of view, the short answer is yes. But there may be a better way to achieve greater gains.

Is breast screening worth it?

Australia’s breast screening program was announced by then-prime minister Bob Hawke in the midst of the 1990 election campaign.

But the benefits of the program haven’t been entirely political. A 2009 cost effectiveness analysis showed that the program cost A$38,302 for each year of life gained. That is a good deal compared to other health investments. Dietary counselling from a GP for people at greater than 5% risk of heart disease, for instance, costs about A$35,000 for every disability adjusted life year gained.

Although assumptions in cost effectiveness analysis of breast screening have been challenged because it doesn’t account for the the anxiety created by screening programs, this report is the best evidence we’ve got.

The government’s decision to extend the age range of women eligible can be seen as economically reasonable because of the reduced cost per year of life gained. Economic rationality and rationing is not a euphemism for budget cutting. Based on current evidence, expanding these services is the right thing to do.

Comparative cost per year of life gained of different policy designs. 2009 Cost effectiveness report

But here’s the rub. Extending the age range down to 45 and up to 74 is even better on cost-effectiveness criteria. With that policy, the cost per year of life gained from screening would be A$37,612 compared to the current A$38,302 – a 2% improvement. Small, yes, but important in the overall scheme of things.

Cost effectiveness isn’t the only relevant criterion, though, even for the econocrat. Extending the age range both upward and downward would cost much more money than just an upward change. In tight budgetary times the larger extension, although economically worthwhile, may have been a budget step too far.

Roads not taken

Yet, if increasing the age range were combined with efforts to cut the cost of screening, we might be able afford the best of both worlds: even more breast cancer screening without hurting the budget bottom line. Cost-effective expansions and budget integrity might both have been feasible.

The 2009 cost effectiveness report also examined changes to current practice and identified several ways to save money, while still saving lives. Increasing the screening interval from two to three years is certainly cost effective and would save significantly on budget outlays. The government could easily afford an age range expansion in both directions if that change were implemented.

Changes in who can conduct and read mammograms are also cost effective. Currently, every mammogram is examined independently by two radiologists. One cheaper and more cost-effective option assessed was to have the second reading done by a specially trained reader. Changes in who takes the mammograms – a radiographer assistant rather than a radiographer – would also lower costs.

Grattan Institute

There is still some controversy about breast screening and new evidence is becoming available every day. The 2009 cost-effectiveness study was a “modelling” study, not an assessment in the real world. In contrast to the Australian approach of simply announcing an expansion of breast screening, a similar expansion in the English National Health Service was accompanied by a randomised controlled trial to allow a full evaluation of the new policy.

It’s puzzling why a similar strategy was not followed here, especially in the light of recent calls for more health services research in Australia to contribute to policy development.

Burgeoning health outlays

Health expenditure is rising rapidly. Budget setting is about priority setting (the soft way to say “rationing”). But the rationing discussion should follow, not replace or precede, the efficiency discussion. The extra money to expand screening to wider age groups could have been offset completely by improved efficiency.

Current policy settings in breast screening “ration” the public program to women aged 50-69. The government has just announced a new “rationing” regime, to target women 50-74, and this indeed is a rational expansion, as far as it goes.

But the real rationing question is: in hard economic times, why aren’t we pursuing other breast-screening initiatives – such as changing the screening interval and using a different mix of health professionals – that are more economically rational and save more money?

This is the ninth part of our series Health Rationing. Click on the links below to read the other instalments:

Part one: Tough choices: how to rein in Australia’s rising health bill
Part two: Explainer: what is health rationing?
Part three: A conversation that promises savings worth dying for
Part four: Phase out GP consultation fees for a better Medicare
Part five: Focus on prevention to control the growing health budget
Part six: Health funding under the microscope – but what should we pay for?
Part seven: Comparing apples, pears and hips: health rationing at work
Part eight: Who gets a piece of the pie? Spending the health budget fairly

Join the conversation

9 Comments sorted by

  1. Elizabeth Hart

    Independent Vaccine Investigator

    How does this pre-election announcement by Federal Health Minister Tanya Plibersek sit with information in the Cochrane Intervention Review "Screening for breast cancer with mammography"? Here's some information from the abstract:

    QUOTE

    Main Results: Eight eligible trials were identified. We excluded a biased trial and included 600,000 women in the analyses. Three trials with adequate randomisation did not show a significant reduction in breast cancer mortality at 13 years (relative risk (RR…

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    1. ian cheong

      logged in via email @acm.org

      In reply to Stephen Duckett

      Breast cancer screening has always been of marginal benefit. The fullness of data appears to support no net benefit to women's health. This review indicates that breast cancer mortality is reduced but all cause mortality is not. Implying that treatment increases death from other causes.

      The younger age group is more prone to harm from overdiagnosis of benign breast disease. The older age group would be more prone to death from side effects of treatment.

      If there is actually zero net longevity benefit, then the cost per life saved becomes rather large - approaching infinite.

      Mortality data does not include accounting for negative effects of screening and treatment.

      Zero net longevity for finite cost makes a negative economic benefit - see http://www.thennt.com/nnt/screening-mammography-for-reducing-deaths/.

      This policy is a clear case of vote buying not rational evidence-based policy.

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    2. Stephen Duckett
      Stephen Duckett is a Friend of The Conversation.

      Director, Health Program at Grattan Institute

      In reply to ian cheong

      Maybe. For better or for worse the 2009 cost-effectiveness analysis was the best evidence the Government had. Both you and Elizabeth are arguing that there is better evidence and that should have been used. There is contention still in this area, which makes the case for an accompanying randomised controlled trial even stronger.

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  2. Greg Byrne

    logged in via Facebook

    In regard to "A rational response to breast screening", an even more rational response would be for anti-cancer Councils and researchers to make available to women information already available on reducing the risk of breast cancer. While healthy diet, no smoking and low alcohol intake are emphasised, reproductive risk factors are censored because of political correctness. Here are the facts women and young girls should know because prevention is better than diagnosis and treatment:

    * The…

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    1. Lynne Newington

      Researcher

      In reply to Greg Byrne

      I have a t least three thoughts on this.
      1. For clergy who didn't abide by church ruling on contraception and there were those who didn't with health issues as the result, should they be held accountable, for disobedience.
      2. The benefits of women taking the pill, with it's mentioned side effects, certainly was advantageous for their partners.
      3. Let men have "the snip", then there would be no unwanted pregnancies including for clergy, promoting The Billings Method that ultimately failed.

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  3. Greg Byrne

    logged in via Facebook

    Dear Lynne
    We have long given up trying to prescribe or proscribe on contraception. What we are saying is that women should be fully informed about any documented health risks in regard to contraception or abortion. I'm sure that both sides of the debate would agree that women should be fully informed about any health risks pertaining to "reproductive issues". Those of us who follow conservative social values will continue doing so with the attendant health benefits. We may commend this course of conduct to other people for their own good. However we have no right to go beyond commending it. If you are awaiting some sort of scriptural quotation on the morality or otherwise of artificial contraception you will be waiting a long time.

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    1. Lynne Newington

      Researcher

      In reply to Greg Byrne

      Considering certain areas I pointed out it would be blasphemy to even consider mentioning scripture.
      What I am saying is, there were sympathetic clergy towards the use of contraception, against church teaching, there have been women who did suffer the consequences with side effects and you can follow the rest of that part of my comment.
      The second, the Billings method introduced didn't work for everyone, including for clergy who were promoting it, not they should have been experimenting considering their vows of chastity.
      Thirdly let the men be the ones to take the chances with losing their whatever can happen or go wrong and let the women have as clear conscience as far as possible, for Catholics, instead of her looking for those "sympathetic" priests to absolve her to her detriment.
      I just love these men to talk about abortion etc.... women can't conceive on their own.

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