RT Journal
A1 Mandelblatt JS, Tosteson AA, van Ravesteyn NT
T1 Costs, evidence, and value in the medicare program: Comment on “the cost of breast cancer screening in the medicare population”
JF JAMA Internal Medicine
JO JAMA Internal Medicine
YR 2013
FD February 11
VO 173
IS 3
SP 227
OP 228
DO 10.1001/jamainternmed.2013.2127
UL http://dx.doi.org/10.1001/jamainternmed.2013.2127
AB 
The provocative article by Gross et al1 published in this issue examines whether investments in new and more expensive breast cancer screening technologies, such as digital mammography, provide a good return on investment in the care of the growing older US female population. Evidence on the efficacy of digital mammography comes from the American College of Radiology Imaging Network Digital Mammographic Imaging Screening Trial; published in 2005, the trial involved more than 40 000 women of all ages. Digital screening rapidly disseminated into practice in the United States after these results were published. This occurred despite the primary trial finding that there was no overall difference between digital and plain-film mammography in detecting breast cancer, although it was superior for premenopausal or perimenopausal women younger than 50 years with dense breasts. Notably, among women 65 or older, whose breasts have a higher proportion of fat than dense mammary tissue, there was actually a strong trend for digital mammography to perform worse than plain film mammography.2 Yet Medicare has covered this service under its annual breast cancer screening benefit and continues to do so, despite limitations in evidence of benefit for older women and lack of cost-effectiveness.3