Is Adjuvant Therapy for Older Patients with Node (+) Early Breast Cancercost-effective?*
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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.
- Diab, SG, Elledge, RM, Clark, GM (2001) Response: Re: tumor characteristics and clinical outcome of elderly women with breast cancer. J Natl Cancer Inst 93: pp. 65-66 CrossRef
- Diab, SG, Elledge, RM, Clark, GM (2000) Tumor characteristics and clinical outcome of elderly women with breast cancer. J Natl Cancer Inst 92: pp. 550-556 CrossRef
- Yancik, R (1997) Cancer burden in the aged: an epidemiologic and demographic overview. Cancer 80: pp. 1273-1283 CrossRef
- Bouchardy, C, Rapiti, E, Fioretta, G, Laissue, P, Neyroud-Caspar, I, Schafer, P, Kurtz, J, Sappino, AP, Vlastos, G (2003) Undertreatment strongly decreases prognosis of breast cancer in elderly women. J Clin Oncol 21: pp. 3580-3587 CrossRef
- Muss HB: Factors used to select adjuvant therapy of breast cancer in the United States: an overview of age, race, and socioeconomic status J Natl Cancer Inst Monogr 52–55, 2001
- Carlson, RW, Anderson, BO, Bensinger, W, Cox, CE, Davidson, NE, Edge, SB, Farrar, WB, Goldstein, LJ, Gradishar, WJ, Lichter, AS, McCormick, B, Nabell, LM, Reed, EC, Silver, SM, Smith, ML, Somlo, G, Theriault, R, Ward, JH, Winer, EP, Wolff, A (2000) NCCN practice guidelines for breast cancer. Oncology (Huntingt) 14: pp. 33-49
- Carlson, RW, Edge, SB, Theriault, RL (2001) NCCN: breast cancer. Cancer Control 8: pp. 54-61
- Aapro, MS (2001) Adjuvant therapy of primary breast cancer: a review of key findings from the 7th international conference, St. Gallen, February 2001. Oncologist 6: pp. 376-385 CrossRef
- Fisher, B (1969) Systemic chemotherapy as an adjuvant to surgery in the treatment of breast cancer. Cancer 24: pp. 1286-1289
- Effects of adjuvant tamoxifen and of cytotoxic therapy on mortality in early breast cancer. An overview of 61 randomized trials among 28,896 women. Early Breast Cancer Trialists’ Collaborative Group. N Engl J Med 319: pp. 1681-1692
- Systemic treatment of early breast cancer by hormonal, cytotoxic or immune therapy: 133 randomised trials involving 31,000 recurrences and 24,000 deaths among 75,000 women. Lancet 339: pp. 71-85
- Tamoxifen for early breast cancer: an overview of the randomised trials. Early Breast Cancer Trialists’ Collaborative Group. Lancet 351: pp. 1451-1467
- Polychemotherapy for early breast cancer: an overview of the randomised trials. Early Breast Cancer Trialists’ Collaborative Group. Lancet 352: pp. 930-942
- NIH Consensus Statement on Adjuvant Therapy for Breast Cancer. In: 2000 NIH Consensus Conference on Adjuvant Breast cancer, 2000, pp 1–35.
- National Institutes of Health Consensus Development Conference statement: adjuvant therapy for breast cancer, November 1–3, 2000. J Natl Cancer Inst Monogr 5–15, 2001.
- Abrams, JS (2001) Adjuvant therapy for breast cancer – results from the USA consensus conference. Breast Cancer 8: pp. 298-304
- Hillner, BE, Smith, TJ (1991) Efficacy and cost effectiveness of adjuvant chemotherapy in women with node-negative breast cancer. A decision-analysis model. N Engl J Med 324: pp. 160-168
- Hillner, BE, Smith, TJ, Desch, CE (1993) Assessing the cost effectiveness of adjuvant therapies in early breast cancer using a decision analysis model. Breast Cancer Res Treat 25: pp. 97-105 CrossRef
- Hillner, BE (1993) Financial costs, benefits, and patient risk preferences in node-negative breast cancer: insights from a decision analysis model. Recent Results Cancer Res 127: pp. 277-284
- Desch, CE, Hillner, BE, Smith, TJ, Retchin, SM (1993) Should the elderly receive chemotherapy for node-negative breast cancer? A cost-effectiveness analysis examining total and active life-expectancy outcomes. J Clin Oncol 11: pp. 777-782
- Messori, A, Becagli, P, Trippoli, S, Tendi, E (1996) Cost-effectiveness of adjuvant chemotherapy with cyclophosphamide + methotrexate + fluorouracil in patients with node-positive breast cancer. Eur J Clin Pharmacol 51: pp. 111-116 CrossRef
- NCHS: United States Life Tables, 1999. In: National Center for Health Statistics, 1999
- Naeim, A, Keeler, EB (2005) Is adjuvant therapy for older patients with node (-) early breast cancer cost-effective. Crit Rev Oncol Hematol 53: pp. 81-89
- Kattlove, H, Liberati, A, Keeler, E, Brook, RH (1995) Benefits and costs of screening and treatment for early breast cancer. Development of a basic benefit package. JAMA 273: pp. 142-148 CrossRef
- Malin J, Keeler E: Cost-effectiveness and health benefit of breast cancer in women with early breast cancer. In: RAND, Los Angeles, 2000, p 28
- Quiet, CA, Ferguson, DJ, Weichselbaum, RR, Hellman, S (1996) Natural history of node-positive breast cancer: the curability of small cancers with a limited number of positive nodes. J Clin Oncol 14: pp. 3105-3111
- Hillner, BE, Smith, TJ (1995) Cost effectiveness and other assessments of adjuvant therapies for early breast cancer. Oncology (Huntingt) 9: pp. 129-134
- Silber, JH, Fridman, M, Shpilsky, A, Even-Shoshan, O, Smink, DS, Jayaraman, J, Fox, KR, Pauly, MV (1998) Modeling the cost-effectiveness of granulocyte colony-stimulating factor use in early-stage breast cancer. J Clin Oncol 16: pp. 2435-2444
- Fisher, B, Brown, AM, Dimitrov, NV, Poisson, R, Redmond, C, Margolese, RG, Bowman, D, Wolmark, N, Wickerham, DL, Kardinal, CG (1990) Two months of doxorubicin-cyclophosphamide with and without interval reinduction therapy compared with 6 months of cyclophosphamide, methotrexate, and fluorouracil in positive-node breast cancer patients with tamoxifen-nonresponsive tumors: results from the National Surgical Adjuvant Breast and Bowel Project B-15. J Clin Oncol 8: pp. 1483-1496
- Gold, MR (1996) Cost-Effectiveness in Health and Medicine. Oxford University Press, New York
- McNeil, BJ, Weichselbaum, R, Pauker, SG (1978) Fallacy of the five-year survival in lung cancer. N Engl J Med 299: pp. 1397-1401
- Rolison, MR, Scherman, A (2002) Factors influencing adolescents‘ decisions to engage in risk-taking behavior. Adolescence 37: pp. 585-596
- Kerlikowske, K, Salzmann, P, Phillips, KA, Cauley, JA, Cummings, SR (1999) Continuing screening mammography in women aged 70 to 79 years: impact on life expectancy and cost-effectiveness. JAMA 282: pp. 2156-2163 CrossRef
- Du, X, Goodwin, JS (2001) Patterns of use of chemotherapy for breast cancer in older women: findings from Medicare claims data. J Clin Oncol 19: pp. 1455-1461
- Extermann, M (2002) Comorbidity and geriatric assessment in the elderly patient over the age of 70. Tumori 88: pp. S9
- Extermann, M (2003) Studies of comprehensive geriatric assessment in patients with cancer. Cancer Control 10: pp. 463-468
- Extermann, M (2004) Management issues for elderly patients with breast cancer. Curr Treat Options Oncol 5: pp. 161-169
- Mandelblatt, JS, Lawrence, WF, Womack, SM, Jacobson, D, Yi, B, Hwang, YT, Gold, K, Barter, J, Shah, K (2002) Benefits and costs of using HPV testing to screen for cervical cancer. JAMA 287: pp. 2372-2381 CrossRef
- McQuellon, RP, Muss, HB, Hoffman, SL, Russell, G, Craven, B, Yellen, SB (1995) Patient preferences for treatment of metastatic breast cancer: a study of women with early-stage breast cancer. J Clin Oncol 13: pp. 858-868
- Walter, LC, Covinsky, KE (2001) Cancer screening in elderly patients: a framework for individualized decision making. JAMA 285: pp. 2750-2756 CrossRef
- Is Adjuvant Therapy for Older Patients with Node (+) Early Breast Cancercost-effective?*
Breast Cancer Research and Treatment
Volume 94, Issue 2 , pp 95-103
- Cover Date
- Print ISSN
- Online ISSN
- Kluwer Academic Publishers
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- adjuvant treatment
- breast cancer
- hormone treatment
- Industry Sectors
- Author Affiliations
- 1. Division of Hematology-Oncology, Hematology-Oncology UCLA, UCLA Department of Medicine, 10945 Le Conte Avenue, Ste. PVUB, Los Angeles, CA, 90095, USA
- 2. RAND School of Public Policy, Division of Health Services Research, Santa Monica, CA, USA