Breast Cancer Screening in Women Younger Than 50 Years of Age: What's Next?

In this issue, a well-constructed cost-effectiveness analysis of screening mammography in women younger than 50 years of age [1] shows that screening in this age group is expensive, costing approximately $150 000 for a year of life saved. Those who do not like this result will no doubt challenge some details of the analysis, but they will not be able to shake its basic conclusion, which is determined by the low incidence of the disease, the relatively small beneficial effect of screening, and the long delay before any benefit appears. Unless the cost of mammography decreases dramatically, screening in younger women will always be expensive compared with the benefit it provides.

What does this mean? It means that in settings that face limits on resources, which is almost every setting, putting money into this activity instead of more cost-effective activities will do more harm than good. The amount of harm can be estimated by looking at other activities that would be pushed aside. For a nearby example, screening women 50 to 65 years of age delivers about seven times as much benefit per dollar as screening younger women [1], yet only about 60% of women older than age 50 years in the United States are screened regularly. Until that rate is increased to its practical limit of perhaps 90%, every year of life added by preferentially putting resources into screening women in their 40s will be accompanied by about 7 years of life lost because of suboptimal screening in women who develop the disease after 50 years of age. Even if budgets are increased to accommodate the additional costs of mammography in younger women, the net effect will still be more harm than good if the funds could otherwise go toward another activity that would have provided greater benefit. …