Estimating Personal Costs Incurred by Women
Participating in the National Breast & Cervical
Cancer Early Detection Program
Donatus U. Ekwueme, PhD, MS
Senior Health Economist
Division of Cancer Prevention and Control
Presentation at the AcademyHealth
2009 Annual Research Meeting
June 28, 2009
Co-authors
Ingrid J. Hall, PhD, MPH
James G. Gardner, MSPH
Janet Royalty, MS
Disclaimer
The findings and conclusions in this report are
those of the authors and do not necessarily
represent the official position of the CDC
Background


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The National Breast and Cervical Cancer Early Detection Program (NBCCEDP)
is the largest cancer screening program in the United States
Established in 1990 by the US Congress
Provides free breast and cervical cancer screening and diagnostic services to
low-income, uninsured, and underinsured women
Administrated by the Centers for Disease Control and Prevention (CDC)
 All the 50 states
 The District of Columbia

5 US territories
 12 American Indian/Alaska Native tribal organizations
Background (Cont’d)
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Eligibility
 At or below 250% of the federal poverty level
 Ages 40-64 years for breast cancer screening
 Ages 18-64 years for cervical cancer screening
Direct clinical services provided
 Clinical breast examinations
 Mammograms
 Pap tests
 Diagnostic testing for women with abnormal screening results
 Surgical consultation
 Referrals to treatment
Non-direct clinical services
 Public education/outreach
 Professional education
 Coalition and partnership
Characteristics of Women Receiving
Breast Cancer Screening within NBCCEDP
Distribution by Race/Ethnicity
Distribution by Age
Characteristics of Women Receiving
Cervical Cancer Screening within NBCCEDP
Distribution by Race/Ethnicity
Distribution by Age
NBCCEDP Accomplishments

Provided screening and diagnostic tests to over 3.3 million women

Over 8.0 million screening examinations

Diagnosed over 37,000 breast cancers

Diagnosed over 2,000 invasive cervical cancers

Over 121,500 pre-malignant cervical lesions, of which 42% were high-grade

Currently reaching
 ≤ 15% of the eligible women aged 40-64 for breast cancer
 ≤ 7% of the eligible women aged 18–64 years for cervical cancer
Rationale for this Study

“Free” is relative term implying that finances are the only costs that women
consider in participating in the program
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Does not cover personal costs, such as opportunity costs and transaction
costs
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Opportunity costs may include costs associated with travel time, waiting time,
time spent receiving screening services, distance traveled to and from
screening, loss of leisure time, and loss of productivity in the workplace or at
home
Transaction costs are out-of-pocket costs and may include transportation,
childcare and/or dependent care, parking, and other expenses related to
participation

The Demand-side analysis

The Supply-side analysis
Objectives
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To estimate personal costs incurred by women participating in the
NBCCEDP by race/ethnicity
To estimate the lifetime personal costs that these women may incur
in participating in the program
Methods: Data
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Survey of mammography rescreening (SMR)
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SMR is a retrospective cohort study among women who had a
mammogram in 1997 through the NBCCEDP in Maryland, New York,
Ohio, and Texas
Study participants were interviewed by telephone at least 30 months
after their 1997 index mammogram, the interview took place between
July 1999 and November 2000
A total of 2,095 women age 50-69 years old were interviewed
This study used a sample of 1,870 women between ages 50 to 64 years
old

US Census

Literature review
Table 1. Input Variables
WN-Hispanic
Mean (Range)
BN-Hispanic
Mean (Range)
Hispanic
Mean (Range)
Other Mean
(Range)
Race/ethnicity %
41.5 (40.5-42.5)
16.0 (15.2-17.6)
34.0 (33.5-36.1)
9.1 (8.6-10.2)
Child/dependant care
time %
5.7 (4.1-7.6)
9.7(6.5-13.8)
14.8 (11.7-18.3)
12.4 (7.4-19.1)
Paid for transportation %
10.0 (7.7-12.8)
31.1 (25.5-37.2)
25.7 (21.8-30.0)
38.9 (30.0-48.3)
Paid for parking %
6.2 (4.4-8.5)
5.7 (3.1-9.6)
6.1 (3.9-9.0)
12.8 (6.8-21.3)
Work/leisure time loss %
------------------
100
------------------
------------------
Used mass transit %
------------------
1.8 (.01-10.0)
------------------
------------------
Fringe benefit %
------------------
0.224
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Total hrs worked per yr
------------------
2080
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Calculation of Costs Incurred by Women
Cost incurred by women by race/ethnicity =
Cost to women participating in mammography screening =
[((Sum of the time the woman spent traveling round-trip x travel time
index), waiting time, and exam time x (mean hourly wage x (1+ fringe
benefit))
+ (Mileage traveled round-trip x cost per mile x proportion who
traveled in their own vehicle)
+ (Sum of distance traveled x cost of mass transit fare per mile x
proportion who used mass transit)
+ (Proportion needing child/dependent care x cost of child/dependent
care per hour x number of hours of child/dependent care service)
+ (Proportion who paid for parking x cost of parking)]
x Proportion of each racial/ethnic group who responded to the survey
x Number of women screened in the program from 2005-2006
Adjusted for recall rates
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Adjusted for recall rates
Proportion of women returning for either immediate diagnostic follow-up or
for follow-up within 9 months of the index mammogram or Pap test
Breast cancer

40-49 = 14.3% - 25.7%

50-64 = 12.0% - 16.5%
Cervical cancer

18-39 = 9.5% - 15.3%
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40-49 = 5.6% - 7.4%

50-64 = 4.1% - 5.1%
Calculation of Lifetime Costs Incurred by women
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A woman would receive a mammogram
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A woman would receive a Pap test
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age 40-75 yrs = 15 to 25 times
age 50-75 yrs = 10 to 25 times
Cytology age 18 or 21- 65 yrs = 7 to 25 times
Cost incurred by women at age 40 or 50 yrs is constant up to age 64
years
A woman aged 50 reaches age 65 yrs, she may incur lower personal
cost from participating based on the possibility of Medicare coverage
and retirement at age 65
Finally, cost incurred was discounted at an annual rate of 3% to account
for the present value of the lifetime costs incurred
Estimation Equation
T
PV of lifetime cost r/e =
∑
Cr / e
(1 + r )
T'
+
∑
t
=t i =
t ' 65
Where
 PV = present value

i = 18, 40, 50

r/e = racial/ethnic group
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Cr/e = cost incurred at age 50 through 64 years
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T = age 64 years
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C’r/e = cost incurred at age 65 through 74 years

T’ = age 74 years
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r = annual discount rate
C 'r / e
(1 + r )
t'
The model
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The model was parameterized using data presented in Table 1
We calculated personal costs incurred according to the participants’
race/ethnicity

Non-Hispanic white

Non-Hispanic black

Hispanic, and
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Non-Hispanic other
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We conducted the analysis from the women’s viewpoint

All costs were expressed in 2005 US dollars
Decision Analysis Model
Baseline Results of Personal Costs Incurred by
Women by Income and Race/Ethnicity
Breast cancer
40-49
50-64
$366,120
$4,837,905
$36.61
$483.79
$170,058
$3,076,596
$17.01
$307.66
$17,969
$378,800
$1.80
$37.88
$165,480
$1,240,268
$16.55
$124.03
$12,612
$142,241
$1.26
$14.22
All race/ethnicity
Total cost
Cost/10,000 women
White Non-Hispanic
Total cost
Cost/10,000 women
Black Non-Hispanic
Total cost
Cost/10,000 women
Hispanic
Total cost
Cost/10,000 women
Other Non-Hispanic
Total cost
Cost/10,000 women
Baseline Results of Personal Costs Incurred by
Women by Income and Race/Ethnicity
Cervical cancer
18-39
40-49
50-64
$57,142
$635,307
$753,341
$5.71
$63.53
$75.33
$31,855
$424,107
$525,191
$3.19
$42.41
$52.52
$2,455
$39,414
$55,522
$0.25
$3.94
$5.55
$19,342
$153,125
$150,608
$1.93
$15.31
$15.06
$3,489
$18,661
$22,020
$0.35
$1.87
$2.20
All race/ethnicity
Total cost
Cost/10,000 women
White Non-Hispanic
Total cost
Cost/10,000 women
Black Non-Hispanic
Total cost
Cost/10,000 women
Hispanic
Total cost
Cost/10,000 women
Other Non-Hispanic
Total cost
Cost/10,000 women
Importance of this study
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Program cost + Personal cost = Societal cost
For example
 Previously published program costs per woman*
 Breast cancer = $105.09
 Cervical cancer = $59.75
Assuming 1-time screening
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Societal cost
 breast cancer
50-64 yrs: $143.18
 cervical cancer 50-64 yrs:
$66.79
The calculated societal cost can be used by policy makers for program planning
and by researchers to estimate societal cost-effectiveness of the NBCCEDP
Example illustrates the usefulness of quantifying the economic costs incurred by
the demand-side (patients) in participating in a preventive cancer screening program
* Ekwueme DU, et al. Cost Analysis of the National Breast and Cervical Cancer Early Detection
Program Selected States, 2003 to 2004. Cancer 2008;112:626–35
Limitations
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We did not account for the cost of the potential side effects associated with
breast and cervical cancer screening
For example, if there is a false positive result, then the woman could experience
unnecessary anxiety and distress and possibly receive costly medical
procedures to alleviate her emotional distress
The survey did not collect information on mode of travel, distance traveled, time
traveled, or time spent in mammography clinic
We obtained data on these variables from the literature in a similar population
participating in mammography screening and Pap tests
Conclusions
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In both breast and cervical cancers and for all age-groups, white non-Hispanic
women incurred the highest cost.
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On the other hand, non-Hispanic women of other races incurred the lowest cost.
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For both breast and cervical cancers, >90% of personal cost incurred was
attributable to opportunity costs
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Capturing and quantifying personal costs will help ascertain the total cost (i.e.,
societal cost) of providing mammography screening and Pap testing to medically
underserved, low-income women participating in a publicly funded cancer
screening program
Will help determine the cost-effectiveness of such a program
Thank You !!!
Contact Information: Donatus U. Ekwueme, PhD
dce3@cdc.gov; 770-488-3182