The United States spent $43 billion annually on screening to prevent five cancers, according to one of the most comprehensive estimates of medically recommended cancer testing ever produced.
The analysis, published on Monday in The Annals of Internal Medicine and based on data for the year 2021, shows that cancer screening makes up a substantial proportion of what is spent ever year on cancer in the United States, which most likely exceeds $250 billion. The researchers focused their estimate on breast, cervical, colorectal, lung and prostate cancers, and found that more than 88 percent of screening was paid for by private insurance and the rest mostly by government programs.
Dr. Michael Halpern, the lead author of the estimate and a medical officer in the federally funded National Cancer Institute’s health care delivery research program, said his team was surprised by the high cost, and noted that it was likely to be an underestimate because of the limits of the analysis.
For Karen E. Knudsen, the chief executive of the American Cancer Society, the value of screening for the cancers is clear. “We are talking about people’s lives,” she said. “Early detection allows a better chance of survival. Full stop. It’s the right thing to do for individuals.”
“We screen for cancer because it works,” Dr. Knudsen added. “The cost is small compared to the cost of being diagnosed with late-stage disease.”
Other researchers say the finding supports their contentions that screening is overused, adding that there is a weak link between early detection and cancer survival and that the money invested in cancer testing is not being well spent.
Colonoscopies are a big source of screening costs, accounting for 55 percent of the total. The cost is driven, Dr. Halpern said, by the fees charged by the medical or surgical centers where colonoscopies are performed.
Dr. David Lieberman, a specialist in colon cancer screening speaking for the American Gastroenterological Association, said that while the cost of colonoscopies was high, the test could prevent cancer as well as detect it. Surgeons can see and cut out growths on the colon wall that occasionally can turn into cancers, thereby stopping a cancer before it can take hold.
The test, he said, has “a large upstream cost and potential downstream benefits.”
Critics of the current amount of screening said the large price tag researchers documented for screening wasn’t worth the cost.
“What are we actually getting of value for that amount of money?” asked Dr. Adewole Adamson, a dermatology researcher at the University of Texas at Austin who studies screening.
“If it was actually doing something I could say, ‘Yes, it is justified,’” he said. But, he added, studies repeatedly failed to show that people live longer if they are screened. And, he said, screening barely lowers the death rate from the cancer being screened — some cancers are deadly from the start, and detecting them may not help.
“People have an outsized idea of what the benefits are,” Dr. Adamson said.
But supporters of screening point to the recommendations of the U.S. Preventive Services Task Force, an independent and influential group that issues advice on preventive health. The task force’s guidance has broad impact in the United States, setting standards for health insurance coverage. It conducted its own analyses of the data on screening and recommended it to reduce the death rates for four of the five cancers in the study, with evidence strongest for cervical cancer and colorectal cancer. For prostate cancer, it recommended neither for nor against screening and is currently updating its analysis.
And while preventive testing against cancer could be carried out more efficiently, advocates for the practice argue it remains necessary.
“Too many people undergo screening who are unlikely to benefit, but many more who could benefit have never been screened or are not screened regularly,” Dr. Knudsen said.
She added that “the value of screening is settled science.”
Cancer death rates have been plummeting in the past few decades. Experts debate the reasons, but Dr. H. Gilbert Welch, a senior researcher in the Center for Surgery and Public Health at Brigham and Women’s Hospital who wrote an editorial that accompanied the paper, said it was a mistake to attribute that solely, or even mostly, to screening.
With colon cancer, for example, the death rate has been on a linear decline for 40 years, falling by nearly 50 percent from the 1980s — when few were screened — to today, when about 50 percent of eligible adults are screened. In an earlier paper published in The New England Journal of Medicine, Dr. Welch reported that the increase in screening did not accelerate the decline.
A much applauded clinical trial concluded that screening could reduce the risk of dying from colorectal cancer over 30 years by one-third. But, Dr. Welch said, in that study the absolute risk fell from 3 percent to 2 percent — a 33 percent drop but just one percentage point. And there was no change at all in the overall mortality rate with screening.
“I’m not saying there is no effect from screening, but it is so small that something else is going on,” Dr. Welch said. And that something, he added, is vastly improved treatment for colon cancer and, he speculated, changing diets and exposures to other factors, like medications that might decrease risk.
The lesson from cancer screening, Dr. Welch said, is that the effects on mortality “are so small it takes huge clinical trials to see them.” Typically, he said, about one person out of 1,000 screened over 10 years will avoid death from that particular cancer.
Dr. Daniel Morgan, who directs the Center for Innovation in Diagnosis at the University of Maryland, said he agreed with Dr. Welch’s assessment of the limits of cancer screening.
“I hope his editorial stimulates a conversation about the true value of screening,” he said.
The issue, he said, is “Should we get screening independent of the cost?”
That matter, Dr. Morgan said, is “one we should continue to discuss.”
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