Assessing the cost effectiveness of adjuvant therapies in early breast cancer using a decision analysis model Cost analysis of diagnosis and treatment in breast cancer — Mini-symposium DOI:
Cite this article as: Hillner, B.E., Smith, T.J. & Desch, C.E. Breast Cancer Res Tr (1993) 25: 97. doi:10.1007/BF00662134 Summary Background: We have developed a decision analysis model that uses the results of available randomized controlled trials to model the natural history of early breast cancer and assess the potential clinical and financial effects of using adjuvant therapies. Patients and Methods: The original model was used to assess the impact of chemotherapy in hypothetical groups of 45-year-old and 60-year-old node-negative, estrogen receptor-negative women. Using the 1992 Early Breast Cancer Trialists' Collaborative Group report, we have expanded and revised the model to assess: 1) the role of tamoxifen alone, chemotherapy alone, or combined therapy in pre-menopausal women, and 2) chemotherapy in elderly women with node-negative, estrogen receptor-negative cancer. Results: For pre-menopausal women, we found that chemotherapy increases quality adjusted life expectancy and survival by a substantial amount at a cost less than most accepted medical interventions. Combined therapy is beneficial and cost-effective in estrogen receptor-positive cancer. For the elderly, chemotherapy prolongs survival but to a lesser extent compared to younger women. The cost of this benefit is high but within the range of commonly reimbursed procedures for women under age 75 without other co-existing conditions. Conclusions: For most patients some form of adjuvant therapy is beneficial and cost-effective. The model builds upon the data derived from collaborative efforts assessing the effectiveness of adjuvant therapies. The model highlights the need for an equal commitment to assessing the economic and quality of life impacts of breast cancer treatments. Key words breast neoplasm cost-effectiveness analysis decision trees medical effectiveness patient preferences
This minisymposium was presented December 8, 1992, at the annual San Antonio Breast Cancer Symposium, and was sponsored by educational grants from Amgen and from Bristol-Myers Oncology Division.
Early Breast Cancer Trialists' Collaborative Group: Systemic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy. Lancet 339:1–15,71-85, 1992.
Hillner BE, Smith TJ: Efficacy and cost effectiveness of adjuvant chemotherapy in women with node-negative breast cancer. A decision-analysis model. N Engl J Med 324:160–168, 1991.
Hillner BE, Smith TJ: Should women with node-negative breast cancer receive adjuvant chemotherapy? — Insights from a decision analysis model. Breast Cancer Res Treat 23:17–27, 1992.
Smith TJ, Hillner BE: The efficacy and cost-effectiveness of adjuvant therapy of early breast cancer in premenopausal women. J Clin Oncol, in press.
Desch CE, Hillner BE, Smith TJ, Retchin SM: Should the elderly receive chemotherapy for node-negative breast cancer? A cost-effectiveness analysis examining total and active life expectancy outcomes. J Clin Oncol, in press.
Pauker SG, Kassirer JP: Decision analysis. N Engl J Med 316:250–258, 1987.
McGuire WL, Tandon AK, Allred DC, Chamness GC, Clark GM: How to use prognostic factors in axillary node-negative breast cancer patients. J Natl Cancer Inst 82:1006–1015, 1990.
Carter CL, Allen C, Henson DE: Relation of tumor size, lymph note status, and survival in 24,740 breast cancer cases. Cancer 63:181–187, 1989.
Rosen PP, Groshen S, Saigo PE, Kinne DW, Hellman S: A long-term follow-up study of survival in stage I (T1N0M0) and stage II (T1N1M0) breast carcinoma. J Clin Oncol 7:355–366, 1989.
Henderson IC: Adjuvant systemic therapy: State of the art, 1989. Breast Cancer Res Treat 14:3–22, 1989.
Levine MN: Quality of life in breast cancer.
Osoba D (ed) Effect of Cancer on Quality of Life. CRC Press, Boca Raton, 1991, pp 205–214.
Gelber RD, Goldhirsch A, Cavalli F: Quality-of-life-adjusted evaluation of adjuvant therapies for operable breast cancer. The International Breast Cancer Study Group. Ann Intern Med 114:621–628, 1991.
Eisenberg JM: Clinical economics. A guide to the economic analysis of clinical practices. JAMA 262: 2879–2886, 1989.
Baker MS, Kessler LG, Urban N, Smucker RC: Estimating the treatment costs of breast and lung cancer. Med Care 29:40–49, 1991.
Coates AS, Simes RJ: Patient assessment of adjuvant treatment inoperable breast cancer.
Williams CJ (ed) Introducing New Treatments for Cancer: Practical, Ethical and Legal Problems. John Wiley & Sons Ltd, New York, 1992, pp 447–458.
Slevin ML, Stubbs L, et al: Attitudes to chemotherapy: comparing views of patients with cancer with those of doctors, nurses, and the general public. Br Med J 300: 1458–1460, 1990.
Detsky AS, Naglie IG: A clinician's guide to cost-effectiveness analysis. Ann Intern Med 113:147–154, 1990.
Levine MN, Gafni A, Markman M, Macfarlane D: A bedside decision instrument to elicit a patient's preference concerning adjuvant chemotherapy for breast cancer. Ann Intern Med 117:53–58, 1992.
Breast Cancer: Setting Priorities for Effectiveness Research. Institute of Medicine, Washington DC, 1990.
Hillner BE, Smith TJ, Desch CE: Efficacy and cost-effectiveness of autologous bone marrow transplantation in metastatic breast cancer — Estimates using decision analysis while awaiting clinical trial results. JAMA 267:2055–2061, 1992.
Weinstein MC, Stason WB: Cost-effectiveness of coronary artery bypass surgery. Circulation 66(Suppl III): III56-III66, 1982.
Welch HG, Larson EB: Cost effectiveness of bone marrow transplantation in acute nonlymphocytic leukemia. N Engl J Med 321:807–812, 1989.
Schulman KA, Lynn LA, Glick HA, Eisenberg JM: Cost-effectiveness of low-dose zidovudine therapy for asymptomatic patients with human immunodeficiency virus (HIV) infection. Ann Intern Med 114:798–802, 1991.
Desch CE, Lasala MR, Smith TJ, Hillner BE: The optimal timing of autologous bone marrow transplantation in Hodgkin's disease patients after a chemotherapy relapse [see comments]. J Clin Oncol 10: 200–209, 1992.
Edelson JT, Weinstein MC, Tosteson ANA, Williams L, Lee TH, Goldman L: Long-term cost-effectiveness of various initial monotherapies for mild to moderate hypertension. JAMA 263:407–413, 1990.
Garner TI, Dardis TI: Cost-effectiveness analysis of end-stage renal disease treatments. Med Care 25:25–34, 1987.
Eddy DM: Screening for breast cancer. Ann Intern Med 111:389–399, 1989.
Weeks JC, Tierney MR, Weinstein MC: Cost effectiveness of prophylactic intravenous immune globulin in chronic lymphocytic leukemia. N Engl J Med 325: 81–86, 1991.
Google Scholar Copyright information
© Kluwer Academic Publishers 1993