Should the elderly receive chemotherapy for node-negative breast cancer? A cost-effectiveness analysis examining total and active life-expectancy outcomes

Systematic review of the evidence sources applied to cost-effectiveness analyses for older women with primary breast cancer

OBJECTIVE

To appraise the sources of evidence and methods to estimate input parameter values in decision-analytic model-based cost-effectiveness analyses of treatments for primary breast cancer (PBC) in older patients (≥ 70 years old).

METHODS

Two electronic databases (Ovid Medline, Ovid EMBASE) were searched (inception until 5 September-2021) to identify model-based full economic evaluations of treatments for older women with PBC as part of their base-case target population or age-subgroup analysis. Data sources and methods to estimate four types of input parameters including health-related quality of life (HRQoL); natural history; treatment effect; resource use were extracted and appraised. Quality assessment was completed by reference to the Consolidated Health Economic Evaluation Reporting Standards.

RESULTS

Seven model-based economic evaluations were included (older patients as part of their base-case (n = 3) or subgroup (n = 4) analysis). Data from younger patients (< 70 years) were used frequently to estimate input parameters. Different methods were adopted to adjust these estimates for an older population (HRQoL: disutility multipliers, additive utility decrements; Natural history: calibration of absolute values, one-way sensitivity analyses; Treatment effect: observational data analysis, age-specific behavioural parameters, plausible scenario analyses; Resource use: matched control observational data analysis, age-dependent follow-up costs).

CONCLUSION

Improving estimated input parameters for older PBC patients will improve estimates of cost-effectiveness, decision uncertainty, and the value of further research. The methods reported in this review can inform future cost-effectiveness analyses to overcome data challenges for this population. A better understanding of the value of treatments for these patients will improve population health outcomes, clinical decision-making, and resource allocation decisions.

Cost-effectiveness of a 21-gene recurrence score assay versus Canadian clinical practice in women with early-stage estrogen- or progesterone-receptor-positive, axillary lymph-node negative breast cancer

BACKGROUND

A 21-gene recurrence score (RS) assay may inform adjuvant systematic treatment decisions in women with early stage breast cancer. We sought to investigate the cost effectiveness of using the RS-assay versus current clinical practice (CCP) in women with early-stage estrogen- or progesterone-receptor-positive, axilliary lymph-node negative breast cancer (ER+/ PR + LN- ESBC) from the perspective of the Canadian public healthcare system.

METHODS

We developed a Markov model to project the lifetime clinical and economic consequences of ESBC. We evaluated adjuvant therapy separately in post- and pre-menopausal women with ER+/ PR + LN- ESBC. We assumed that the RS-assay would reclassify pre- and post-menopausal women among risk levels (low, intermediate and high) and guide adjuvant systematic treatment decisions. The model was parameterized using 7 year follow up data from the Manitoba Cancer Registry, cost data from Manitoba administrative databases, and secondary sources. Costs are presented in 2010 CAD. Future costs and benefits were discounted at 5%.

RESULTS

The RS-assay compared to CCP generated cost-savings in pre-menopausal women and had an ICER of $60,000 per QALY gained in post-menopausal women. The cost effectiveness was most sensitive to the proportion of women classified as intermediate risk by the RS-assay who receive adjuvant chemotherapy and the risk of relapse in the RS-assay model.

CONCLUSIONS

The RS-assay is likely to be cost effective in the Canadian healthcare system and should be considered for adoption in women with ER+/ PR + LN- ESBC. However, ongoing assessment and validation of the assay in real-world clinical practice is warranted.

Tumor gene expression profiling in women with breast cancer. Test category: prognostic

Differences in the expression of specific genes within breast tumors have been associated with risk of recurrence after treatment. Most women with Stage I or II node-negative breast cancer (especially when estrogen-receptor positive and treated with tamoxifen) remain disease-free at 10 years. Information on risk of recurrence could help identify women most likely to benefit from chemotherapy. Several clinically available gene expression profiles (GEP) provide “recurrence risk scores” that are intended to supplement information used by clinicians and patients in treatment decision-making.

Cost Effectiveness of Exemestane versus Tamoxifen in Post-Menopausal Women with Early Breast Cancer in Germany

BACKGROUND: Medical studies have shown that switching to exemestane after 2-3 years of adjuvant treatment with tamoxifen is effective when looking at overall survival. No cost effectiveness study of exemestane has been conducted in the German health care context. PATIENTS AND METHODS: To assess the cost effectiveness of switching to exemestane vs. continued tamoxifen therapy for early-stage breast cancer, a Markov model was developed. The model population was set as postmenopausal women who are in remission from early-stage breast cancer. Upon model entry, either a continuing daily therapy with 20 mg tamoxifen or a switch to 25 mg exemestane for the next 2-3 years takes place. The model takes a German health care perspective. RESULTS: The total incremental costs of exemestane on a lifetime basis are 4,195 Euro, resulting in an incremental cost effectiveness ratio of 17,632 Euro per additional quality-adjusted life year (QALY), or 16,857 Euro per life year gained. Incremental costs per disease-free year of survival are 12,851 Euro. Probabilistic sensitivity analyses proved the robustness of these findings. CONCLUSION: Compared to extended tamoxifen therapy, switching to exemestane after 2-3 years turned out to be a cost-effective strategy in adjuvant therapy for early-stage breast cancer in postmenopausal women within the German health care context.

Evaluation of trends in the cost of initial cancer treatment

BACKGROUND

Despite reports of increases in the cost of cancer treatment, little is known about how costs of cancer treatment have changed over time and what services have contributed to the increases.

METHODS

We used data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database for 306,709 persons aged 65 and older and diagnosed with breast, lung, colorectal, or prostate cancer between 1991 and 2002 to assess the number of patients assigned to initial cancer care, from 2 months before diagnosis to 12 months after diagnosis, and mean annual Medicare payments for this care according to cancer type and type of treatment. Mutually exclusive treatment categories were cancer-related surgery, chemotherapy, radiation therapy, and other hospitalizations during the period of initial cancer care. Linear regression models were used to assess temporal trends in the percentage of patients receiving treatment and costs for those treated. We extrapolated our results based on the SEER data to the US Medicare population to estimate national Medicare payments by cancer site and treatment category. All statistical tests were two-sided.

RESULTS

For patients diagnosed in 2002, Medicare paid an average of $39,891 for initial care for each lung cancer patient, $41 134 for each colorectal cancer patient, and $20,964 for each breast cancer patient, corresponding to inflation-adjusted increases from 1991 of $7139, $5345, and $4189, respectively. During the same interval, the mean Medicare payment for initial care for prostate cancer declined by $196 to $18261 in 2002. Costs for any hospitalization accounted for the largest portion of payments for all cancers. Chemotherapy use increased markedly for all cancers between 1991 and 2002, as did radiation therapy use (except for colorectal cancers). Total 2002 Medicare payments for initial care for these four cancers exceeded $6.7 billion, with colorectal and lung cancers being the most costly overall.

CONCLUSIONS

The statistically significant increase in costs of initial cancer treatment reflects more patients receiving surgery and adjuvant therapy and rising prices for these treatments. These trends are likely to continue in the near future, although more efficient targeting of costly therapies could mitigate the overall economic impact of this trend.

The influence of aging on the early detection, diagnosis, and treatment of breast cancer

Patterns of care for women with breast cancer vary substantially with patient age. Older patients with breast cancer frequently receive less than standard management, resulting in poorer outcome. At diagnosis, the health status of older women with breast cancer affects survival and treatment decisions. Age-related comorbidity may limit diagnostic tests, narrow treatment options, and significantly increase mortality not related to breast cancer. Yet, for healthy older women with early-stage breast cancer, stage-adjusted survival is similar to that of younger women. Calendar age is not sufficient to encompass the heterogeneity in health status of the elderly. Instead, management of older women with breast cancer should be based on anticipated survival, functional status, and the goals of the patient for treatment. In this review, we evaluate pertinent data and provide guidance for the management of older women with breast cancer.

Aromatase inhibitors--socioeconomical issues

With costs of health care in general and for cancer therapy in particular escalating due to implementation of novel compounds, there is an increasing focus on therapy costs in most countries. A common way of assessing therapeutic utility versus cost is by assessing cost per additional life year gained or cost per additional quality-adjusted life year (QALY) gained with a novel therapy. While endocrine therapy in general is associated with low costs, the fact that aromatase inhibitors are administered over several years to each patient in the adjuvant setting, together with the substantial number of postmenopausal breast cancer patients that are candidates for adjuvant treatment with aromatase inhibitors, advocates critical examination of cost-utilities related to implementation of such therapy in the adjuvant setting. While cost-utility estimates for treatment with aromatase inhibitors in the adjuvant setting look favorable, the estimates are sensitive to variations with respect to long-term benefits but also side effects. For patient groups with a low-risk of relapse but also patients with a limited life expectancy due to high age, cost-utility estimates may exceed the upper limits generally proposed for costs per quality-adjusted life year gained.

The return on investment in health care: from 1980 to 2000

OBJECTIVE

To estimate the return on US investment (ROI) in overall health as well as four specific conditions.

METHODS

The study utilized three distinct approaches to "triangulate" the evidence as related to ROI in health care: 1) an estimation of the average ROI in additional health-care service expenditures in the United States for the year 2000 compared with the year 1980, based on US summaries of health expenditures and health outcomes; 2) an estimate of the ROI in Medicare services for the period from 1985 to 2000 for treatment of heart attack, stroke, type 2 diabetes, and breast cancer, based on National Long-term Care Survey data and Medicare claims; and 3) an estimate of the ROI for selected major treatment innovations for the same four conditions during the period from 1975 to 2000.

RESULTS

We calculated that each additional dollar spent on overall health-care services produced health gains valued at Dollars 1.55 to Dollars 1.94 under our base case assumptions. The return on health gains associated with treatment for heart attack, stroke, type 2 diabetes, and breast cancer were Dollars 1.10, Dollars 1.49, Dollars 1.55, and Dollars 4.80, respectively, for every additional dollar spent by Medicare. The ROI for specific treatment innovations ranged from both savings in treatment costs and gains in health to gains in health valued at Dollars 1.12 to Dollars 38.00 for every additional dollar spent.

CONCLUSION

The value of improved health in the US population in 2000 compared with 1980 significantly outweighs the additional health-care expenditures in 2000 compared with 1980.

An unadjusted NNT was a moderately good predictor of health benefit

BACKGROUND AND OBJECTIVE

Whether the number needed to treat (NNT) is sufficiently precise to use in clinical practice remains unclear. We compared unadjusted NNTs to quality-adjusted life years (QALYs) gained, a more comprehensive measures of health benefit.

STUDY DESIGN AND SETTING

From a subset (n = 65) of a dataset of 228 cost-effectiveness analyses, we compared how well NNTs predicted clinically important QALY gains using correlation analysis, multivariable models and receiver-operator curve (ROC) analysis.

RESULTS

NNT was inversely correlated with QALY gains (P < .001); this relationship was affected by quality of life and life-expectancy gains of treatment (P <or= .04). The NNT is a moderately accurate predictor of treatments that provide large health benefits (area under ROC 0.74-0.81). For ruling out therapies with low QALY gains (threshold <or=0.125 to <or=0.5 QALYs), an NNT >15 had a sensitivity of 82% to 100%. For ruling in therapies with high QALY gains (threshold >or=0.125 to >or=0.5 QALYs), an NNT <or=5 had a specificity of 77%.

CONCLUSION

Using NNT thresholds of <or=5 and >15 to rule in and out therapies with large QALY gains may provide general guidance regarding the magnitude of health benefit.

Risk assessment for cancer surgery in elderly patients

Global growth of the elderly population is requiring healthcare providers to cater for an expanding elderly cancer subpopulation. The aggression with which cancer should be treated in this subpopulation is an ethical dilemma and is an ongoing debate, as surgeons have feared increases in postoperative morbidity and mortality. As a result elderly patients often receive suboptimal cancer treatment. The need for standardization of cancer surgery is well recognized despite the difficulties in view of heterogeneity of the group. In this article, epidemiological changes, tumor biology specific to elderly cancer are visited, operative risk assessment tools are discussed, and interim results of ongoing multinational investigation ie, PACE (Preoperative Assessment of Cancer Elderly) revealed.

When to recommend and to pay for first-line adjuvant breast cancer treatment? A structured review of the literature

A structured review of studies on the health-economic evaluation of systemic adjuvant therapy for early-stage breast cancer was carried out. Of the eight articles that have been identified four were related to the cost-effectiveness of chemotherapy, three compared chemotherapy with combined chemotherapy and hormonal therapy and one compared tamoxifen (TAM) with third-generation aromatase inhibitors (ATIs). Results of the review indicate that the cost-utility of adjuvant breast cancer therapy is within the range of other oncological interventions. Adjuvant chemotherapy is most cost-effective in pre-menopausal women with node-positive breast cancer while cost-effectiveness decreases considerably with increasing age. Endocrine therapy with TAM is most cost-effective in ER-positive tumours with no significant age effect. The cost-utility of using the ATI anastrozole instead of TAM in adjuvant therapy cannot be conclusively assessed on the basis of the existing evidence.

Special issues related to breast cancer adjuvant therapy in older women

Increasing age remains the major risk factor for breast cancer and more than half of all breast cancers in North America and the European Union occur in women 65 years and older. Anticipated life expectancy, co-morbidity, and functional status must all be considered when offering systemic adjuvant treatment to older women. Tamoxifen significantly decreases the risk of recurrence and improves survival in all women with hormone receptor-positive invasive breast cancer, including women 70 years and older. More recently, aromatase inhibitors have been shown to be even more effective than tamoxifen in reducing breast cancer recurrence in postmenopausal women, and are an appropriate choice for initial endocrine therapy in older women. Adjuvant chemotherapy improves survival in postmenopausal women, but adds little to endocrine therapy in the majority of women with node-negative, hormone receptor-positive tumors. Chemotherapy should be considered for patients with high-risk node-negative, hormone receptor-negative tumors and those with node-positive tumors. Co-morbidity and its effect on survival should be factored into all chemotherapy decisions. Older women are frequently under-treated and are still under-represented in clinical trials; sometimes this represents good clinical judgment, but age bias alone can result in under-treatment and higher breast cancer-related mortality or state-of-the-art trials not being offered to older, but otherwise eligible, patients. Physician education and more clinical trials designed for older women are needed.

Is Adjuvant Therapy for Older Patients with Node (+) Early Breast Cancercost-effective?*

BACKGROUND

Node (+) breast cancer represents over 40% of cases in older women and currently there is a debate whether adjuvant therapy for all older women is cost-effective.

PURPOSE

To evaluate if adjuvant treatment for early-stage (Stage I-IIIa) node (+) breast cancer with hormone therapy, chemotherapy, or combination therapy is cost-effective in older patients.

DESIGN

A decision-analysis model for 65, 75, and 85 year-old female breast cancer patients using life tables integrated the cost of treatment in dollars and impact in length and quality of life. Both estrogen receptor (ER) (-) and (+) patients were considered. The primary data sources were meta-analysis from the Early Breast Cancer Trialists' Collaborative Group and the Red Book Average Wholesale Price for drugs. The cost of treatment in dollars and impact of quality of life was examined. Scenarios were used when treatment benefit was uncertain. The incremental cost-effectiveness of different treatment strategies were then compared and mapped graphically.

RESULTS

Adjuvant therapy is cost-effective in 65 year-old women with early breast cancer. In a 75 year-old ER (+) patient, hormone therapy is cost-effective, $10,965/quality-adjusted life years (QALY), but chemotherapy was more cost-effective, $27,406/QALY, if one assumed it was as efficacious as in a 65 year-old woman. In a 75 year-old ER (-) patient, chemotherapy was cost-effective at $42,605 with the same assumption. In an 85 year-old ER (+) patient, hormone therapy was cost-effective, $26,463/QALY, if efficacy is not age-sensitive, but chemotherapy was not as cost-effective for either ER (+) or ER (-) patients.

CONCLUSION

Treatment decisions for older breast cancer patients suffer from the lack of sufficient clinical trial data. Decision-analytic models can help policy makers who are faced with decisions about whether to support adjuvant therapy in older breast cancer patients and also outline the important parameters that need to be considered in such a decision.

Update in Medical Oncology for Older Patients

Breast cancer is a disease of older women, and its incidence continues to rise with the growth and aging of the U.S. population. Elderly women have frequently been under-treated and have been poorly represented in clinical breast cancer trials. We reviewed the literature on early breast cancer in older women. We present current information on the tumor biology of elderly women and the role of surgical therapy and adjuvant treatment with hormonal therapy, chemotherapy, biologic agents, and radiation therapy in its management. Lastly, we discuss the importance of clinical trials in the elderly and future directions for therapy.

Aromatase inhibitors--socio-economical issues

Novel, third-generation aromatase inhibitors are currently implemented for treatment of postmenopausal breast cancer in the metastatic and adjuvant setting and, potentially, for breast cancer prevention. Introduction of novel therapeutic strategies to large patient groups may add significant costs to health care budgets, forcing institutions to focus entirely on costs or the cost-utility of implementing such novel strategies. Breast cancer is the most frequent cancer in the female population in western societies, and its incidence is currently increasing in other parts of the world as well. Due to the proven efficacy and limited side effects of endocrine therapy in the adjuvant setting, the indications for use have been successively broadened. Currently, the majority of postmenopausal women treated for an estrogen-receptor positive breast cancer will be offered adjuvant endocrine therapy; thus, a general change of practice may cause significant implications to healthcare costs. This may relate to direct drug costs as well as indirect costs related to prevention of side effects, like additional use of bisphosphonates to prevent enhanced bone loss. The aim of this paper is to overview these considerations and put them into perspective by simple illustrations taken from current cost estimates.

Is adjuvant therapy for older patients with node (−) early breast cancer cost-effective?

BACKGROUND

Node (-) breast cancer represents over 60% of cases in older women and currently there is a debate whether adjuvant therapy for these women is cost-effective.

PURPOSE

Evaluate if adjuvant treatment for early-stage node (-) breast cancer with hormone therapy, chemotherapy, or combination therapy is cost-effective in older patients.

DESIGN

Decision-analysis modeling using life tables integrated the cost of treatment in dollars and impact in length and quality of life. The primary data sources were meta-analysis from the Early Breast Cancer Trialists' Collaborative Group and the Red Book Average Wholesale Price for drugs. The incremental cost-effectiveness of different treatment strategies were then compared and mapped graphically.

RESULTS

Adjuvant therapy is cost-effective in 65-year-old women with early breast cancer. In a 75-year-old estrogen receptor, ER (+) patient, hormone therapy, specifically tamoxifen, is cost-effective, 19,530 dollars/QALY. In a 75-year-old ER (-) the use of chemotherapy (AC or CMF) or 85-year-old ER (+) the use of hormone therapy was only marginally cost-effective, 54,000-76,000 dollars/QALY, only if efficacy was assumed to be age-insensitive (similar to a 65-year-old woman).

CONCLUSION

Decision-analytic models can help policy makers who are faced with decisions about whether to support adjuvant therapy in older breast cancer patients and also outline the important parameters that need to be considered in such a decision.

Benefits and Costs of Interventions to Improve Breast Cancer Outcomes in African American Women

Purpose

Historically, African American women have experienced higher breast cancer mortality than white women, despite lower incidence. Our objective was to evaluate whether costs of increasing rates of screening or application of intensive treatment will be off-set by survival benefits for African American women.

Methods

We use a stochastic simulation model of the natural history of breast cancer to evaluate the incremental societal costs and benefits of status quo versus targeted biennial screening or treatment improvements among African Americans 40 years of age and older. Main outcome measures were number of mammograms, stage, all-cause mortality, and discounted costs per life year saved (LYS).

Results

At the current screening rate of 76%, there is little incremental benefit associated with further increasing screening, and the costs are high: $124,053 and $124,217 per LYS for lay health worker and patient reminder interventions, respectively, compared with the status quo. Using reminders would cost $51,537 per LYS if targeted to virtually unscreened women or $78,130 per LYS if targeted to women with a two-fold increase in baseline risk. If all patients received the most intensive treatment recommended, costs increase but deaths decrease, for a cost of $52,678 per LYS. Investments of up to $6,000 per breast cancer patient could be used to enhance treatment and still yield cost-effectiveness ratios of less than $75,000 per LYS.

Conclusion

Except in pockets of unscreened or high-risk women, further investments in interventions to increase screening are unlikely to be an efficient use of resources. Ensuring that African American women receive intensive treatment seems to be the most cost-effective approach to decreasing the disproportionate mortality experienced by this population.

The surgical management of elderly cancer patients

Although cancer in the elderly is extremely common, few health professionals in oncology are familiar with caring for series of oncogeriatric patients. Surgery is at present the first choice, but is frequently delivered suboptimally: under-treatment is justified by concerns about unsustainable toxicity, whilst over-treatment is explained by the lack of knowledge in optimising preoperative risk assessment. This article summarises the point of view of the Surgical Task Force @ SIOG (International Society for Geriatric Oncology), pointing out differences from, and similarities to, the younger cohorts of cancer patients, and highlighting the latest updates and trends specifically related to senior cancer patients.

Cost-effectiveness versus cost-utility analysis of interventions for cancer: does adjusting for health-related quality of life really matter?

OBJECTIVE

The US Public Health Service Panel on Cost-Effectiveness has recommended the use of quality-adjusted life-years (QALYs) as the best way to estimate outcomes in a cost-effectiveness analysis. We evaluate the importance of this recommendation by assessing whether adjusting for health-related quality of life affects the ultimate resource allocation decision implied by the cost-effectiveness ratio for interventions aimed at cancer prevention and control.

METHODS

We identified 110 interventions in 39 articles for which both cost/life-year and cost/QALY were reported. Interventions were forms of prevention, early detection, or treatment of cancer. We calculated a Spearman correlation to assess the ordinal relationship between cost/life-year and cost/QALY. In addition, we employed various decision thresholds to assess whether the use of cost/life-year would yield different resource allocation decisions than the use of cost/QALY.

RESULTS

The correlation between cost/life-year and cost/QALY is 0.96 (P <.0001). Assuming a US dollars 50000 decision threshold, adjustment for quality of life would affect the implied choice in 5% of cases. With a US dollars 400000 threshold, adjustment for quality of life would affect choice for 2% of interventions.

CONCLUSIONS

For interventions aimed at cancer, the outcome measures of cost/life-year and cost/QALY are highly correlated with one another. Although adjusting for quality of life can make an important difference in the evaluation of alternative approaches to cancer prevention and control, it often does not.

Adjuvant therapy for older women with breast cancer

The major risk factor for breast cancer is increasing age and more than half of all breast cancers in affluent nations occur in women 65 years and older. Co-morbidity is a key consideration in offering systemic adjuvant treatment to older women since significant co-morbidity minimizes the potential value of any adjuvant therapy. Tamoxifen has clearly been shown to significantly decrease the risk of recurrence and improve survival in women of all ages who have estrogen (ER) or progesterone receptor (PR) positive invasive breast cancer, including those 70 years and older. Chemotherapy in older patients can improve survival but adds little to tamoxifen in women with node-negative, ER+ or PR+ tumors: it should be reserved for older women who have reasonable life-expectancy and larger node-negative tumors, or node-positive tumors. Ageism is still a barrier to clinical trials participation and clinical trials focusing on older women are needed.

Cost-effectiveness studies in ovarian cancer

Ovarian cancer is the fifth leading cause of cancer-related deaths. The costs associated with this cancer impact both on the affected individual and on the health system. Screening is currently unproven as a strategy for improving outcomes for women with ovarian cancer. Randomized controlled trials, however, are underway, estimating any impact of screening with ultrasound and CA125 on ovarian cancer mortality. Paclitaxel and carboplatin combination, the standard first-line chemotherapy regimen for ovarian cancer, has not been compared with cisplatin and cyclophosphamide regarding the cost-effectiveness and cost-utility, but for paclitaxel and cisplatin, numerous studies have addressed these issues. The estimated incremental costs resulting from these studies fall well within the generally accepted range for new therapies. Although acquisition costs of new chemotherapy drugs exceed those of older drugs, the impact of costly drugs on total costs may be cost saving due to less costs related to supportive and palliative care. The most important costs for the patient, the pain and suffering associated with ovarian cancer and its treatment, are hard to quantify. Nevertheless, patients' quality of life must be considered when making a clinical decision to treat this disease. A review of available cost-effectiveness studies is presented and discussed.

Older women with breast carcinoma are less likely to receive adjuvant chemotherapy: evidence of possible age bias?

BACKGROUND

Older women with breast carcinoma are less likely than younger women to receive adjuvant chemotherapy. The authors hypothesized that after controlling for confounders (i.e., variables related to both age and chemotherapy use) and effect modifiers (i.e., variables that have a significant interaction with age), age would become a less significant factor for predicting adjuvant chemotherapy use.

METHODS

Data on 480 women with localized breast carcinoma were entered into the National Comprehensive Cancer Network database at The Ohio State University Medical Center. Women were divided into 3 groups: women age < 50 years (n = 143 [30%]), women ages 50-65 years (n = 216 [45%]), and women age > 65 years (n = 121 [25%]). Chi-square and Wilcoxon rank sum tests were used for univariate analyses of the variables of interest, and logistic regression was used for multivariate analyses.

RESULTS

After adjustment for confounders (stage, tumor size, progesterone receptor status, and lymph node involvement) and effect modifiers (namely, estrogen receptor [ER] status), the odds of not receiving chemotherapy for women ages 50-65 years and women age > 65 years with ER-positive breast carcinoma were approximately 6 (odds ratio [OR], 6.4; 95% confidence interval [CI], 3.1-13.3; P < 0.001) and 62 (OR, 62.4; 95% CI, 21.8-178.7; P < 0.001) times greater, respectively, than the odds for women age < 50 years. Women ages 50-65 years with ER-negative breast carcinoma were not significantly different from women age < 50 years with respect to chemotherapy use (OR, 1.9; 95% CI, 0.5-7.3; P = 0.374). However, the odds of not receiving chemotherapy for women age > 65 years with ER-negative breast carcinoma were 7 times (OR, 6.7; 95% CI, 1.5-30.6; P = 0.013) greater than the odds for women age < 50 years.

CONCLUSIONS

The results of the current study indicate that based on older age alone, women are less likely to receive adjuvant chemotherapy. In addition, the results suggest that age bias may contribute to undertreatment and lack of accrual of older women into clinical trials.

Updates in surgical oncology for elderly patients

Elderly patients affected by solid tumours are frequently encountered on the surgical ward. Prejudice regarding operative risks and long term outcomes may alter their surgical management. Large series of elderly cancer subjects have been analysed and conclusive data are now available, to better tailor their management. Specific epidemiological data are presented in this review, screening programs critically considered, treatment procedures discussed, and the effectiveness of follow-up protocols is analysed together with cost effectiveness issues. Quality of life issues should not be neglected, and a continuous educational endeavour targeted at specialists and general practitioners is desirable.

Using cost-effectiveness analysis to define a breast cancer benefits package for the uninsured

OBJECTIVES

In 1999, California was considering legislation to fund breast cancer treatment for its uninsured. We sought to define the most cost-effective breast cancer benefits package in order to inform this debate.

METHODS

We use cost-effectiveness analysis to calculate the additional costs and benefits of various adjuvant therapy strategies, radiation after breast conserving surgery, and reconstruction compared to those of surgery alone in order to define the most cost-effective breast cancer benefits package for uninsured women.

RESULTS

Using cost-effectiveness analysis, we define a Minimum Breast Cancer Benefits Package that includes only the most cost-effective life-saving breast cancer treatments. To provide these benefits for an estimated 550 breast cancer patients will cost $10,200,000. We present two options that each cost an additional $1,700,000 - to expand the benefits to these patients to include post-mastectomy radiation and breast reconstruction; or to provide the Minimum Package to an additional 93 uninsured women.

CONCLUSIONS

California legislators must decide whether to offer comprehensive benefits to a limited number of breast cancer patients or to provide only the most life-saving treatments to a greater number of women.

Factors used to select adjuvant therapy of breast cancer in the United States: an overview of age, race, and socioeconomic status

Age, race, and socioeconomic status all play a role in decisions regarding breast cancer adjuvant therapy. Increasing age remains the major risk factor for breast cancer, while in very young women breast cancer may have a poorer prognosis, even when adjusted for disease stage and other variables. More than half of all new breast cancers in the United States occur in women older than 65 years. Because of the higher frequency of coexisting (comorbid) serious illness in older women, the benefits of adjuvant therapy get smaller as age increases. Adjuvant therapy with tamoxifen and/or chemotherapy can statistically significantly improve survival in older women, but older women are less likely to receive chemotherapy and are less likely to be offered participation in clinical trials. Efforts are now under way to overcome age bias among health care providers and to develop clinical trials focusing on older patients. Breast cancer mortality is higher in African-Americans than in white Americans. Although the biologic characteristics of breast cancer are worse in African-Americans, major differences in survival are related to socioeconomic factors and access to care. When matched for disease stage and other major clinical and biologic variables, African-American and white patients have similar survival rates. Few data are available on the effects of adjuvant treatment on early breast cancer outcomes in Hispanic Americans and Asian-Americans. Poverty and lack of insurance are surrogates for poor outcomes; major efforts are needed to guarantee all Americans high-quality cancer care.

Who should not receive chemotherapy? Data from American databases and trials

The demonstration of the effectiveness of chemotherapy in both premenopausal and postmenopausal women, regardless of estrogen receptor (ER) status, raises the question of whether all breast cancer patients should receive chemotherapy. Several patient groups with such a favorable long-term prognosis that they will obtain an extremely small benefit from chemotherapy can be identified. They include patients with lymph node-negative tumors of 1 cm or less in size, those with grade 1 tumors between 1.1 and 2.0 cm in size, and those with tumors of favorable histologic type (tubular and mucinous) up to 3 cm in size. A patient subgroup in which it is not clear that the benefits of chemotherapy routinely exceed the risks is postmenopausal women with ER-positive, lymph node-negative cancers receiving tamoxifen. There is a wide variation in prognosis in this group, and chemotherapy should be reserved for those at high risk of recurrence. Finally, no benefit for chemotherapy in women aged 70 years and older has been identified. The high rate of death from causes other than breast cancer may negate small survival benefits, and after adjustment for quality of life, the duration of treatment exceeds the gain in life expectancy.

Decision-analytic model and cost-effectiveness evaluation of postmastectomy radiation therapy in high-risk premenopausal breast cancer patients

PURPOSE

To present a decision model that describes the clinical and economic outcomes of node-positive breast cancer with and without postmastectomy radiation therapy (PMRT).

METHODS

A Markov process was constructed to project the natural history of breast cancer following mastectomy in premenopausal node-positive women. Biannual hazards of local and distant recurrence without PMRT were derived from a large meta-analysis of adjuvant systemic therapy trials for breast cancer. The addition of PMRT reduced the risk of disease relapse by an odds ratio of 0.69. Costs of PMRT ($11,600) and recurrent breast cancer ($4,250 to 16,200/year) were estimated from available literature. The model projected number of recurrences, relapse-free and overall survival, and costs to 15 years, using a discount rate of 3%. Cost-effectiveness ratios were calculated per incremental year of life and quality-adjusted year of life gained. One- and two-way sensitivity analyses were performed to determine the sensitivity of results to clinical and economic assumptions.

RESULTS

The model projected 15-year relapse-free survival of 52% and 43% with and without PMRT, respectively. Overall survival was increased from 48% to 55% with PMRT, resulting in an incremental 0.29 years of life gained per subject. PMRT increased 15-year costs from $40,800 to $48,100. Cost per year of life gained was $24,900, or $22,600 when survival was adjusted for quality of life. Results of the model were relatively sensitive to radiation therapy cost and breast cancer relapse risk.

CONCLUSION

This analysis suggests that PMRT offers substantial clinical benefits achieved in a cost-effective manner, with an average cost per year of life gained of $24,900. Results of the model were robust under a wide range of clinical and economic parameters.

National Institutes of Health Consensus Development Conference Statement: adjuvant therapy for breast cancer, November 1-3, 2000

OBJECTIVE

Our goal was to provide health-care providers, patients, and the general public with an assessment of currently available data regarding the use of adjuvant therapy for breast cancer.

PARTICIPANTS

The participants included a non-Federal, non-advocate, 14-member panel representing the fields of oncology, radiology, surgery, pathology, statistics, public health, and health policy as well as patient representatives. In addition, 30 experts in medical oncology, radiation oncology, biostatistics, epidemiology, surgical oncology, and clinical trials presented data to the panel and to a conference audience of 1000.

EVIDENCE

The literature was searched with the use of MEDLINE(TM) for January 1995 through July 2000, and an extensive bibliography of 2230 references was provided to the panel. Experts prepared abstracts for their conference presentations with relevant citations from the literature. Evidence from randomized clinical trials and evidence from prospective studies were given precedence over clinical anecdotal experience.

CONSENSUS PROCESS

The panel, answering predefined questions, developed its conclusions based on the evidence presented in open forum and the scientific literature. The panel composed a draft statement, which was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. The draft statement was made available on the World Wide Web immediately after its release at the conference and was updated with the panel's final revisions. The statement is available at http://consensus.nih.gov.

CONCLUSIONS

The panel concludes that decisions regarding adjuvant hormonal therapy should be based on the presence of hormone receptor protein in tumor tissues. Adjuvant hormonal therapy should be offered only to women whose tumors express hormone receptor protein. Because adjuvant polychemotherapy improves survival, it should be recommended to the majority of women with localized breast cancer regardless of lymph node, menopausal, or hormone receptor status. The inclusion of anthracyclines in adjuvant chemotherapy regimens produces a small but statistically significant improvement in survival over non-anthracycline-containing regimens. Available data are currently inconclusive regarding the use of taxanes in adjuvant treatment of lymph node-positive breast cancer. The use of adjuvant dose-intensive chemotherapy regimens in high-risk breast cancer and of taxanes in lymph node-negative breast cancer should be restricted to randomized trials. Ongoing studies evaluating these treatment strategies should be supported to determine if such strategies have a role in adjuvant treatment. Studies to date have included few patients older than 70 years. There is a critical need for trials to evaluate the role of adjuvant chemotherapy in these women. There is evidence that women with a high risk of locoregional tumor recurrence after mastectomy benefit from postoperative radiotherapy. This high-risk group includes women with four or more positive lymph nodes or an advanced primary cancer. Currently, the role of postmastectomy radiotherapy for patients with one to three positive lymph nodes remains uncertain and should be tested in a randomized controlled trial. Individual patients differ in the importance they place on the risks and benefits of adjuvant treatments. Quality of life needs to be evaluated in selected randomized clinical trials to examine the impact of the major acute and long-term side effects of adjuvant treatments, particularly premature menopause, weight gain, mild memory loss, and fatigue. Methods to support shared decision-making between patients and their physicians have been successful in trials; they need to be tailored for diverse populations and should be tested for broader dissemination.

The consequence of undertreating breast cancer in the elderly

BACKGROUND

Recent studies have noted that a large fraction of elderly patients do not receive conventional treatment for breast cancer. The consequences of undertreatment of the elderly have not been adequately assessed.

STUDY DESIGN

The senior author's database (PIT) was used to identify women undergoing potentially curative operations for breast cancer between 1978 and 1998. Risk factors, presentation, pathologic findings, treatment, and outcomes of 206 women aged over 70 years were compared with those of 920 younger patients. In addition, conventionally treated and "undertreated" elderly patients were identified, and their characteristics and outcomes were compared.

RESULTS

Older patients' cancers were more often visible on mammography, usually as a mass; younger patients' mammograms were less frequently positive, presenting more often with calcifications (p = 0.002). Cancers of the elderly were better differentiated (p < 0.001) and more likely to be estrogen- and progesterone-receptor positive (p < 0.001; p = 0.007). Patients over 70 had fewer mastectomies (19% versus 33%; p < 0.001) and were also less likely to undergo axillary node dissection (71% versus 81%, p = 0.006), postoperative radiation (69% versus 92%, p < 0.001), and chemotherapy (18% versus 48%, p < 0.001). Fifty-seven percent of older patients were treated with tamoxifen compared with 36% of younger patients (p < 0.001). Elderly patients' rates of local and distant recurrence were comparable to those of younger patients after both mastectomy and breast conservation. Ninety-eight patients (54%) over 70 were undertreated by conventional criteria. Undertreated elderly patients were significantly older (78 versus 76 years, p = 0.003), were diagnosed with excisional biopsy more often (69% versus 57%, p = 0.069) and with fine-needle aspiration less frequently (22% versus 38%, p = 0.069), and were more likely to have breast conservation (90% versus 73%, p = 0.004). Local and distant disease-free survival rates of both groups were comparable. Tamoxifen treatment significantly reduced the chance of developing distant metastasis in node-negative elderly patients with invasive tumors (p = 0.028). Omission of chemotherapy had no impact on disease control in the elderly. Axillary node status and estrogen-receptor status were significantly related to local disease-free survival, and axillary node status was significantly related to distant disease-free survival in multivariate analysis in the elderly.

CONCLUSIONS

Elderly breast cancer patients are frequently treated with breast conservation, omitting axillary dissection, radiation therapy, and chemotherapy. Despite undertreatment by conventional criteria, the rates of local recurrence and distant metastasis are not increased in comparison with conventionally treated elderly patients. Tamoxifen should be administered to elderly breast cancer patients with invasive tumors because it significantly improves distant control.

Operable breast cancer

Breast cancer is the most common malignancy among American women. As a result of widespread screening, most patients present with operable breast cancer that is treated with curative intent. It is well established that the appropriate use of adjuvant therapy improves the disease-free and overall survival of patients with breast cancer. Adjuvant systemic therapy options include tamoxifen for hormone receptor-positive patients, and systemic polychemotherapy. It is standard clinical practice to administer adjuvant systemic therapy to patients with node-positive and high-risk, node-negative breast cancer.

Systematic overview of cost-utility assessments in oncology

PURPOSE

Cost-utility analyses (CUAs) present the value of an intervention as the ratio of its incremental cost divided by its incremental survival benefit, with survival weighted by utilities to produce quality-adjusted life years (QALYs). We critically reviewed the CUA literature and its role in informing clinical oncology practice, research priorities, and policy.

METHODS

The English-language literature was searched between 1975 and1997 for CUAs. Two readers abstracted from each article descriptions of the clinical situation and patients, the methods used, study perspective, the measures of effectiveness, costs included, discounting, and whether sensitivity analyses were performed. The readers then made subjective quality assessments. We also extracted utility values from the reviewed papers, along with information on how and from whom utilities were measured.

RESULTS

Our search yielded 40 studies, which described 263 health states and presented 89 cost-utility ratios. Both the number and quality of studies increased over time. However, many studies are at variance with current standards. Only 20% of studies took a societal perspective, more than a third failed to discount both the costs and QALYs, and utilities were often simply estimates from the investigators or other physicians.

CONCLUSION

The cost-utility literature in oncology is not large but is rapidly expanding. There remains much room for improvement in the methodological rigor with which utilities are measured. Considering quality-of-life effects by incorporating utilities into economic studies is particularly important in oncology, where many therapies obtain modest improvements in response or survival at the expense of nontrivial toxicity.

What threshold for adjuvant therapy in older breast cancer patients?

PURPOSE

To consider the question of when to prescribe adjuvant treatment for elderly breast cancer patients, particularly when comorbidities are present. Knowledge of the threshold relapse risks above which adjuvant treatment is worth prescribing would enhance decision making.

PATIENTS AND METHODS

A Markov analysis of data from the medical literature was conducted. Patients aged 65 to 85 years were considered, along with three levels of comorbidity. The threshold risk of relapse at 10 years (RR10), at which time treatment provides absolute reduction or reduction of an absolute 1% in relapse or mortality, was evaluated.

RESULTS

The threshold RR10 for an absolute reduction in mortality risk by adjuvant treatment was low through the age of 85 years. However, for an absolute 1% reduction, the effect of treatment on relapse and the effect of treatment on mortality increasingly diverged. The threshold RR10 for an absolute 1% reduction in relapse risk remained fairly low (5% to 6% for tamoxifen, 12% to 19% for chemotherapy). The threshold RR10 for an absolute 1% reduction in mortality risk, although starting close to the RR10 for an absolute 1% reduction in relapse risk, rose sharply. For tamoxifen, the difference between the two was 4% for an average 65-year-old, 6% at the age of 75 years, and 15% at the age of 85 years. For chemotherapy, the differences were 6%, 12%, and 30%, respectively. Similarly, thresholds increased with increasing comorbidity. In older and sicker patients, the maximum benefit was reached after 5 years rather than 10 years.

CONCLUSION

Older breast cancer patients can expect a reduction in relapse that is fairly similar to that of younger patients. However, the effect on mortality diverges markedly, and attention should be paid to this difference in clinical decision making. Comorbidity should be considered in recommendations for adjuvant treatment, including clinical practice guidelines.

Doctor-patient communication patterns in breast cancer adjuvant therapy discussions

OBJECTIVE: To identify variables within the patient-oncologist communication pattern that impact overall patient comprehension and satisfaction within the breast cancer adjuvant therapy (AT) setting. SETTING AND PARTICIPANTS: Fifty patients were recruited from a number of academic and community-based oncology practices. Fifteen oncologists participated. MAIN VARIABLES: Three communication variables were identified: percentage of total utterances spoken by the patient, percentage of total physician utterances that were coded as affective (i.e. emotional), and total number of questions asked by the patient during the consultation. Knowledge and satisfaction were assessed by a variety of outcome measures, including knowledge items and satisfaction as measured by VASs, the satisfaction with decision scale and the decisional conflict scale. RESULTS: The level of patient knowledge about breast cancer and satisfaction with the clinical encounter showed a tendency to correlate with the variables measuring aspects of patient-physician communication style. Patients who spoke more or asked more questions tended to be more knowledgeable whilst patients whose physicians used more affective language tended to know less but to be more satisfied with their clinical encounter. CONCLUSIONS: In order to optimize patients' degree of comprehension and satisfaction with their breast cancer adjuvant therapy, physicians need to increase their affective participation in clinical encounters whilst encouraging patients to ask questions and to actively participate in the decision-making process.

Breast cancer and aging. Clinical interactions

The incidence and mortality rates of breast cancer increase with age. As the geriatric population grows, the number of breast cancer cases will reach epidemic proportions. The number of coexisting medical conditions also increases with advancing age. The presence and severity of comorbid conditions influences an individual's ability to tolerate procedures and treatments and must be considered in making disease-management decisions. Screening mammography can potentially save lives in older women. Women whose life expectancy exceeds 5 years should continue annual screening mammography. Choices for local definitive therapy, systemic adjuvant therapy, and treatment of metastatic disease should be based on patient preference and ability to tolerate the planned procedure. In general, otherwise healthy older women should be offered the same treatment options given to younger, postmenopausal women. Alternative, less aggressive, or nonstandard approaches are warranted in women whose life expectancy is limited or who are unable or unwilling to undergo standard management procedures.

Analysis of the eligibility of published economic evaluations for transfer to a given health care system. Methodological approach and application to the French health care system

CONTEXT

Economic evaluations are costly and cannot always be carried out locally. Therefore, decision-makers may wish to use studies already performed in other settings.

OBJECTIVE

To define a method for assessing the eligibility of published economic evaluations for transfer to a given health care system and apply it to the french health care system in the clinical situation of adjuvant therapy for women with breast cancer.

METHODS

(1) Literature search in six databases from 1982 to 1996; (2) critical appraisal of articles based on four inclusion criteria; and (3) assessment of the eligibility of the studies for transfer based on five indicators.

RESULTS

We identified 26 published economic evaluations concerning adjuvant therapy in women with breast cancer. Six (23%) met all four criteria used to select studies, but none of these studies were eligible for transfer to the french health care system. The main reason was that cost data was not reported in a transparent way.

CONCLUSIONS

To improve the transferability of economic evaluations, we recommend that requirements for data provision in publications be standardized and international collaboration strengthened.

A study on the cost effectiveness of sestamibi scintimammography for screening women with dense breasts for breast cancer

The potential impact of Sestamibi scintimammography (SSMM) on the cost effective management of women with dense breasts is not known. This study addresses this issue quantitatively by examining the impact of SSMM based screening strategies on the approximately 3,000,000 women over 40 with very dense breasts (DY patterns) without palpable masses and who have had one or more prior mammograms, who undergo routine screening each year. Quantitative decision tree sensitivity analysis was used to compare the conventional mammography (MM) strategy (strategy A), which does not subject patients with negative mammograms to any further examination until their next screening, with two decision strategies for screening with SSMM; SSMM after a negative mammogram (strategy B) or SSMM as the only screening test for women already identified as having dense breasts by a previous mammogram (strategy C). Cost effectiveness was measured by calculating the incremental cost effectiveness ratio (ICER) of strategies B and C, which is the cost of achieving an additional year of life in the screening population by choosing a SSMM based decision strategy rather than the conventional strategy. Strategies B and C reduced the number of false negative diagnoses by 62% and 8%, respectively. The ICER was $632,000 and $3.18M per life year for strategy B and C, respectively. To be cost effective, the pre-test probability of cancer in the study population must be greater than 3% for strategy B or the cost of SSMM must be less than $50 for strategy C. These results show the ICER of an SSMM based breast cancer screening strategy in the management of patients with dense breasts is not currently within the range (approximately $50,000 per year life saved) of other commonly performed medical interventions that are considered cost effective.

Assessing the cost-effectiveness of postmastectomy radiation therapy

PURPOSE

To assess the cost-effectiveness of postmastectomy local-regional radiation therapy (RT) for patients with breast cancer with regard to local-regional relapse (LRR) and quality-adjusted life years (QALY).

METHODS AND MATERIALS

Data from the literature are used to estimate the risk of LRR, and the impact of RT on the risk of LRR and survival. The risk of LRR is related linearly to the number of positive axillary nodes 1% rate of LRR = 10 + (4 x number of positive nodes)]. RT reduces the risk of LRR by 67%. LRRs are treated with excision or biopsy followed by RT; half being controlled locally and half receiving additional salvage surgery and chemotherapy. Absolute improvements in 10-year overall survival due to RT are assumed to vary between 1 and 12%; and accrue linearly during the initial 10-year follow-up period. Professional and technical charges are used as a surrogate for costs. Money spent and benefits recognized in future years are discounted to 1997 values using a 3% annual rate. Quality factors are used to adjust for treatment, disease, and toxicity status.

RESULTS

The cost per LRR prevented with the addition of routine postmastectomy RT is highly dependent upon the number of positive axillary nodes and ranges from $100,000-$200,000 for patients with 0-2 nodes, and $25,000-$75,000 for > or = 4 nodes. The cost per QALY gained at 10 years is $10,000-$110,000 for survival benefits > or = 3%.

CONCLUSIONS

The cost per LRR prevented decreases with increasing numbers of positive axillary nodes. There is not a sharp cutoff at the < or = 3 vs. > or = 4 lymph node number, suggesting that using this cutoff for recommending or not recommending RT following mastectomy is not economically logical. The cost per QALY of $10,000-$100,000 compares favorably to that of other accepted medical procedures. Modest changes in the quantitative assumptions do not qualitatively alter the results. Concerns regarding costs should not generally preclude the use of postmastectomy RT.

Cost-effectiveness analysis of paclitaxel and cisplatin versus cyclophosphamide and cisplatin as first-line therapy in advanced ovarian cancer. A European perspective

Paclitaxel is a new cytotoxic agent that has demonstrated significant activity in advanced ovarian cancer. The aim of this study was to determine the cost structure of advanced ovarian cancer and the cost-effectiveness of paclitaxel-cisplatin (PC) combination therapy compared with a standard cyclophosphamide-cisplatin (CC) regimen at first-line therapy. The analysis was performed separately for six European countries: Germany, Spain, France, Italy, The Netherlands and the U.K. The study was conducted from the national health service payer's perspective. The total cost of treatment per patient (six cycles of chemotherapy) in the six European countries varied between a minimum of US$4,926 in the U.K. and US$12,578 in Germany for the CC regimen and between US$13,038 and US$24,487 for the PC regimen (April 1996). Since the new regimen improved life expectancy by 1.283 years compared with CC, the incremental cost-effectiveness of PC was calculated to be between US$6,403 per 5-year saved in the U.K. and US$11,420 per life-year saved in Italy. Overall, the cost-effectiveness of PC compares favourably with other oncological interventions. The findings of this study suggest that healthcare decision makers should consider paclitaxel, in combination with cisplatin, as a cost-effective first-line therapy for patients with advanced ovarian cancer.

Chemotherapy in the elderly

Much of the increase in cancer incidence is explained by the increasing number of elderly in the population. Even at a relatively advanced age, many have a life expectancy in the range of, or longer than, the expected 5- or 10-year survival of the malignant disease diagnosed. There are some specific problems related to treatment with chemotherapy in this age group. There is a decline in organ function, especially renal and cardiac, as well as other limitations in relation to vision, hearing and mobility. This means that we have to adopt a different attitude both to indications for chemotherapy and to what agents to use. Social and socioeconomic factors also have to be taken into consideration.

Use of quality-of-life outcome assessments in current cancer clinical trials

During the past decade, the importance of integrating quality of life with other indicators of efficacy in cancer clinical trials has been emphasized. This article reviews quality-of-life assessment in clinical trial reports. All empirical studies using patient ratings published in the Journal of Clinical Oncology from 1992 to 1996 were identified. Of these, 59 articles (4%) included quality-of-life assessment, most frequently measured by self-report questionnaires. Most articles reported clinical trials of symptom management or treatment. Future research needs to specify relationships between quality of life, toxicity, and survival. Continued development of this field requires more frequent inclusion of quality of life in clinical studies.

The cost-effectiveness of routine postoperative radiotherapy after sector resection and axillary dissection for breast cancer stage I. Results from a randomized trial

BACKGROUND

Cost-effectiveness of routine postoperative radiotherapy after breast-conserving surgery has not been prospectively evaluated earlier. In times of rationing of medical resources, valid assessments of cost-effectiveness are important for rational allocation of resources.

PURPOSE

Cost and cost-effectiveness of routine postoperative radiotherapy was calculated in a prospective randomized trial comparing sector resection plus axillary dissection with (XRT group) or without (non-XRT group) postoperative radiotherapy in breast cancer stage I. Three hundred eighty-one patients were included. After a median follow-up of five years 43 local recurrences, six of them in the XRT-group occurred (P < 0.0001). No difference in regional and distant recurrence (P = 0.23) or survival (P = 0.44) was observed.

PATIENTS AND METHODS

Direct medical costs as well as indirect costs in terms of production lost during the treatment period and travel expenses were estimated from data in the medical records and the national insurance registry of each patient. Average costs of different treatment activities and measures were estimated for the XRT-group and the non-XRT group respectively. From these estimates differences in costs and effectiveness between the groups were calculated and marginal cost-effectiveness ratios were estimated. For the construction of QALYs each life-year was quality-adjusted by a utility value depending on which health state the patient was considered to perceive.

RESULTS

Taking into account the cost of primary treatment, the cost of follow-up, the cost of treatment of a local recurrence, travel expenses and indirect costs (production lost) excluding costs for treatment of regional and distant recurrence the cost per avoided local recurrence at five years was SEK 337,727 ($44,438, Pounds 27,018). Adjustment for quality of life showed a cost for every gained QALY to be SEK approximately 1.6 million, ($210,526, Pounds 128,000), range SEK 0.2-3.9 million ($26,315-513,158, Pounds 16,000-312,000).

CONCLUSION

The cost of routine postoperative radiotherapy after sector resection and axillary dissection in breast cancer stage I per avoided local recurrence and gained QALY is high. The cost per gained QALY show great variation depending on utility value, which in this study was derived from external observers and not from the patients themselves. These results stress the importance of identifying risk factors for local recurrence, better understanding of impact on quality of life of a local recurrence and adding cost evaluations to clinical trials in early breast cancer.

Dollars may not buy as many QALYs as we think: a problem with defining quality-of-life adjustments

The scale of health state quality that should be used to compute quality-adjusted life years (QALYs) ranges from 0 (death) to 1.0 (excellent health); this is called the "Q" scale. But many cost-utility analyses (CUAs) in the literature use the upper anchor of the scale to denote only the absence of the particular health condition under investigation, and weight the disease state proportional to this endpoint; these are called "q" scales. Computations using q-scale health-state weights ignore the fact that the average patient is still subject to chronic and acute conditions comorbid with the condition being analyzed; the absence of a particular condition is not in general the same as excellent health, i.e., the Q scale is longer than a q scale. CUAs based on q scales yield "qALYs." Incremental $/qALY ratios are generally lower than $/QALY ratios; in the example presented, $/qALY must be inflated by about 15% to yield $/QALY. Other CUAs correctly weight disease states using the Q scale, but erroneously assign a quality weight of 1.0 to absence of the disease in the CUA computations. The results of such analyses are called "NP-QALYs," as the correction factor to compute QALYs is not a simple proportional adjustment. The authors suggest that analysis doing cost-utility analyses without access to primary data from treated patients use average age-specific health-related quality-of-life weights from population-based studies to represent the state of not having a particular disease. Consumers of CUAs should closely examine the nature of the QALYs in any published analyses before making decisions based on their results.