title: The danger of applying uniform clinical policies across populations: the case of breast cancer in American Indians.
abstract: OBJECTIVE
  This study examined the implications of annual screening mammography for cost and mortality in American Indian populations with differing baseline breast cancer rates.
  
  
  METHODS
  A decision tree compared annual screening mammography and screening clinical breast examination with referral for diagnostic mammography when appropriate. The decision tree was constructed to examine the effect of different base-line cancer rates, stage at diagnosis, and stage-specific survival. Outcomes included 5-year relative survival, deaths prevented at 5 years, cost per death prevented, and total costs.
  
  
  RESULTS
  The findings suggest that the total cost of breast cancer is 3.6 times higher with the screening mammography program but results in a 27.9% reduction in breast cancer deaths over the first 5 years of the program. Both costs and deaths prevented are sensitive to the incidence of breast cancer in the population and are less favorable in the range of incidence seen in American Indians.
  
  
  CONCLUSIONS
  The cost and impact of a given strategy for cancer screening vary among communities with different disease incidence, stage at diagnosis, and stage-specific survival, as seen in American Indian populations.
authors.affiliation: Department of Family Medicine, University of Colorado Health Sciences Center, Denver 80220.
authors.forename: P A
authors.initials: PA
authors.lastname: Nutting
authors.forename: B N
authors.initials: BN
authors.lastname: Calonge
authors.forename: D C
authors.initials: DC
authors.lastname: Iverson
authors.forename: L A
authors.initials: LA
authors.lastname: Green
mesh_terms: D000328:Adult; D000368:Aged; D000413:Alaska / Q000453:epidemiology; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000453:epidemiology / Q000401:mortality; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D015994:Incidence; D007198:Indians, North American; D008327:Mammography / Q000191:economics* / Q000592:standards; D008403:Mass Screening / Q000191:economics* / Q000592:standards; D008875:Middle Aged; D016134:Organizational Policy; D015206:Southwestern United States / Q000453:epidemiology; D014481:United States; D016549:United States Indian Health Service / Q000458:organization & administration* / Q000592:standards; D026712:Value of Life