Cancer screening costs $43 billion – what do we get for that spending?

By Noelle Serino | September 3, 2024

A recent study led by researchers with the National Cancer Institute is the first to put a price tag on the five most common cancer screenings in the U.S. Here are some of their key findings:

The authors estimated the total cost of breast, cervical, colorectal, lung, and prostate cancer screening at $43 billion in 2021. That’s not including the cost of most follow-up tests and procedures that can result from screening.
About 88% of the total cost of screening was paid by private insurers, with the remainder paid by government programs and uninsured patients.
Colonoscopies were the most expensive type of screening, accounting for 55% of the total screening cost. That’s because colonoscopies are more intensive than a scan or blood draw, and facility fees can be high.

These findings make it even more important to avoid inappropriate screening, understand the benefits and harms of screening, and target screening to those most at risk.

That’s a lot of money…but it’s also an underestimate

As Dr. H. Gilbert Welch, general internist at Brigham and Women’s Hospital, pointed out in an editorial in the Annals of Internal Medicine, the $43 billion doesn’t account for overuse of screening or the downstream costs of screening harms.

Americans are frequently screened for cancer inappropriately, either when they are too young (when the risk of cancer is very low and false positive rates are high), too old (when the risk of dying from other conditions is much higher than the risk of dying from cancer), or too frequently.

In one study, nearly half of older participants were over-screened for colorectal, cervical, or breast cancer. Another study found that one-quarter of cancer centers recommend that men be screened for prostate cancer without a shared decision making conversation first, as recommended by federal guidelines. An evaluation of six studies including 250,000 colonoscopies found that the rate of overuse (i.e., receiving a colonoscopy at a non-recommended age or frequency) ranged from 17% to 25.7%. And there are other types of cancer screening that are not recommended – such as screening for skin cancer, full-body MRIs, and liquid biopsies – which have costs not accounted for in this study.

The $43 billion estimate also excludes follow-up tests and procedures associated with many types of screening. Also known as “care cascades,” additional treatment such as more scans and biopsies can cause physical and financial harm. In a survey of nearly 400 US internists, more than half reported that care cascades caused physical, psychological, and financial harm to their patients several times a year. The cost of cascade events can be especially harmful for patients with high-deductible plans.

What are we getting for $43 billion in spending?

If screening works as intended, it means that we’re catching cancer at an early stage before it gets worse, which would save both lives and money. But that’s not always how screening works. Often, screening picks up slow-growing cancers that would not have harmed the patient (this is known as overdiagnosis), resulting in stressful and costly follow-up treatment. And sadly, screening does not always prevent cancer deaths. For example, screening for breast cancer prevents only eight out of 28 breast cancer deaths for every 1,000 women screened over their lifetime. Every life saved is crucial, but it’s important to understand that screening is not a panacea.

“What are we actually getting of value for that amount of money?”
– Dr. Adewole Adamson, dermatology researcher at the University of Texas at Austin, in The New York Times

While screening can prevent some cancer-related deaths, there’s little evidence that cancer screening makes us live longer overall. A 2023 study looked at 18 long-term randomized clinical trials of six common cancer screening tests to understand how many years of life were gained with screening. They found that one test, sigmoidoscopy for colorectal cancer, showed a significant increase in life gained of 110 days for people who were screened, compared to those who were not screened. But the other screening tests did not show a statistically significant increase in lifespan in the screening group.

Why does cancer screening have such a small effect on mortality? Some researchers speculate that the benefits of screening that some people receive get washed out by the harms that others experience. Treatments for some cancers have also improved over the years, which makes early detection less impactful.

What else could this money do for preventing cancer deaths?

Is screening the best use of $43 billion to prevent cancer deaths? In his editorial, Welch argues that “resources devoted to cancer screening would be better directed toward ensuring widespread access to effective cancer treatment.” There are still major disparities by race, income, and insurance status when it comes to accessing recommended cancer treatment, with the high cost of care as a barrier. Forty billion dollars could go a long way toward subsidizing cancer treatment for low-income patients and reducing these care gaps.

The $43 billion invested in cancer screenings could also be used to invest in research on treatments or addressing risk factors of cancer like smoking and environmental exposures. Researchers and legislators are already taking on these challenges. In 2022, the National Cancer Institute invested $6.8 billion in cancer-related research. In the past four years, through their Cancer Moonshot, the Biden administration has invested in policies such as the Toxic Substances Control Act, committing to restricting environmental toxins and pollutants linked to cancer. The $43 billion spent on cancer screenings would be enough to significantly increase investments in cancer research, cover the cost of cleaning up all per- and polyfluoroalkyl substances (PFAS) from wastewater in Minnesota, and support thousands of individuals in enrolling in intensive smoking cessation treatment programs.

Balancing the benefits and harms

These new findings on the high cost of cancer screening make it even more important to avoid inappropriate screening and to ensure that patients understand the benefits and harms. Here are a few ways we can prevent harm and waste from overscreening:

Target the highest-risk patients for cancer screening to maximize the benefits. For example, Dr. Laura Esserman, a surgeon and breast cancer oncologist at the University of California, San Francisco, is piloting an initiative to replace annual mammograms with recommended screening schedules based on factors like age, lifestyle, and breast density.
Provide incentives or behavioral “nudges” for doctors to only screen eligible patients for cancer based on USPSTF guidelines.
Engage in more patient/community education around the benefits and harms of cancer screening with easy-to-understand tools like “theater visuals.”

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