Cost-effectiveness of an exercise and nutritional intervention versus usual nutritional care during adjuvant treatment for localized breast cancer: the PASAPAS randomized controlled trial
We undertook a cost-effectiveness analysis (CEA) to compare an exercise and nutritional program with the usual nutritional care concomitant to adjuvant chemotherapy in localized breast cancer patients. The CEA was designed as part of the interventional, controlled, randomized, single-center, open-label PASAPAS study. Breast cancer patients receiving first-line adjuvant chemotherapy at a French Comprehensive Cancer Center were randomized 2:1 to a 6-month exercise program of supervised indoor and outdoor group sessions in addition to usual nutritional care (exercise arm) or a usual nutritional care group receiving dietary and physical activity counseling (control arm). Costs were assessed from the French national insurance perspective (in Euros, 2012). Incremental cost-effectiveness ratios (ICERs) were calculated for four criteria: body mass index, waist circumference, body fat percentage, and estimated aerobic capacity. Uncertainty around the ICERs was captured by a probabilistic analysis using a non-parametric bootstrap method. The analysis was based on 60 patients enrolled between 2011 and 2013. Average intervention costs per participant were €412 in the exercise arm (n = 41) and €117 (n = 19) in the control arm. Total mean costs were €17,344 (standard deviation 9,928) and €20,615 (standard deviation 14,904), respectively, did not differ significantly (p = 0.51). The 6-month exercise program was deemed to be cost-effective compared with usual care for the estimated aerobic capacity. Multicenter randomized studies with long-term costs and outcomes should be done to provide additional evidence. Clinical trial: The PASAPAS study is registered under ClinicalTrials.gov. Trial registration ID: NCT01331772.
KeywordsBreast cancer Cost-effectiveness analysis Physical activity Dietary care
body mass index
incremental cost-effectiveness ratios
National Authority for Health
The authors received funding from the French Institut National du Cancer (2010-228/VO-HO), the Ligue contre le cancer (PME 2010-2011), the Fondation de France (2010-15024), the Association Nationale de la Recherche et de la Technologie (CIFRE/ANRT no. 426/2010) and the Cancéropôle Lyon Auvergne Rhône-Alpes (Programme structurant 2010).
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflicts of interest.
This study was approved by the French Ethics Committee (Comité de Protection des Personnes Sud-Est IV, No.11-023), the National Security Agency of Medicines and Health Products that applies for biomedical studies (Agence Nationale de Sécurité du Médicament et des produits de santé, No.B110268-80), and the French National Committee on Informatics and Privacy (Commission Nationale de l’Informatique et des Libertés).
Informed consent was obtained from all individual participants included in the study.
- 2.OCDE (2018) Screening, survival and mortality for breast cancer. 160–161. https://doi.org/10.1787/health_glance_eur-2018-42-en
- 8.Handbook of Cancer Survivorship | Michael Feuerstein | SpringerGoogle Scholar
- 10.Mutrie N, Campbell AM, Whyte F, McConnachie A, Emslie C, Lee L, Kearney N, Walker A, Ritchie D (2007) Benefits of supervised group exercise programme for women being treated for early stage breast cancer: pragmatic randomised controlled trial. BMJ 334:517. https://doi.org/10.1136/bmj.39094.648553.AE CrossRefPubMedPubMedCentralGoogle Scholar
- 11.Vardar Yağlı N, Şener G, Arıkan H, Sağlam M, İnal İnce D, Savcı S, Çalık Kutukcu E, Altundağ K, Kaya EB, Kutluk T, Özışık Y (2015) Do yoga and aerobic exercise training have impact on functional capacity, fatigue, peripheral muscle strength, and quality of life in breast cancer survivors? Integr Cancer Ther 14:125–132. https://doi.org/10.1177/1534735414565699 CrossRefPubMedGoogle Scholar
- 12.Mishra SI, Scherer RW, Snyder C et al (2012) Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev:CD008465. https://doi.org/10.1002/14651858.CD008465.pub2
- 13.Pierce JP, Stefanick ML, Flatt SW, Natarajan L, Sternfeld B, Madlensky L, al-Delaimy WK, Thomson CA, Kealey S, Hajek R, Parker BA, Newman VA, Caan B, Rock CL (2007) Greater survival after breast cancer in physically active women with high vegetable-fruit intake regardless of obesity. J Clin Oncol Off J Am Soc Clin Oncol 25:2345–2351. https://doi.org/10.1200/JCO.2006.08.6819 CrossRefGoogle Scholar
- 16.Touillaud M, Foucaut A-M, Berthouze S, Reynes E, Kempf-Lépine AS, Carretier J, Pérol D, Guillemaut S, Chabaud S, Bourne-Branchu V, Perrier L, Trédan O, Fervers B, Bachmann P (2013) Design of a randomised controlled trial of adapted physical activity during adjuvant treatment for localised breast cancer: the PASAPAS feasibility study. BMJ Open 3:e003855. https://doi.org/10.1136/bmjopen-2013-003855 CrossRefPubMedPubMedCentralGoogle Scholar
- 17.Foucaut A-M, Morelle M, Kempf-Lépine A-S, Baudinet C, Meyrand R, Guillemaut S, Metzger S, Bourne-Branchu V, Grinand E, Chabaud S, Pérol D, Carretier J, Berthouze SE, Reynes E, Perrier L, Rebattu P, Heudel PE, Bachelot T, Bachmann P, Fervers B, Trédan O, Touillaud M (2019) Feasibility of an exercise and nutritional intervention for weight management during adjuvant treatment for localized breast cancer: the PASAPAS randomized controlled trial. Support Care Cancer 27:3449–3461. https://doi.org/10.1007/s00520-019-4658-y CrossRefPubMedGoogle Scholar
- 18.Ministère de la Santé et des Solidarités (2006) Deuxième Programme national nutrition santé, 2006–2010—Actions et mesures. ParisGoogle Scholar
- 19.ENC MCO | Stats ATIH. https://www.scansante.fr/applications/enc-mco. Accessed 19 Mar 2019
- 20.Drummond MF, Sculpher MJ, Torrance GW et al (2005) Methods for the economic evaluation of health care programmes, 3rd edn. OUP Oxford, OxfordGoogle Scholar
- 23.Eschenbach PE of EMT (2010) Engineering economy: applying theory to practice, 3 Har/Cdr. Oxford University Press, USA, New YorkGoogle Scholar
- 24.Haute Autorité de Santé - Choices in methods for economic evaluation. https://www.has-sante.fr/portail/jcms/r_1499251/en/choices-in-methods-for-economic-evaluation?portal=r_1482172&userLang=en. Accessed 8 Nov 2017
- 25.Gridchyna I, Aulois-Griot M, Maurain C, Bégaud B (2012) How innovative are pharmaceutical innovations? The case of medicines financed through add-on payments outside of the French DRG-based hospital payment system. Health Policy 104:69–75. https://doi.org/10.1016/j.healthpol.2011.11.007 CrossRefPubMedGoogle Scholar
- 26.Mourgues C, Gerbaud L, Leger S et al (2014) Positive and cost-effectiveness effect of spa therapy on the resumption of occupational and non-occupational activities in women in breast cancer remission: a French multicentre randomised controlled trial. Eur J Oncol Nurs 18:505–511. https://doi.org/10.1016/j.ejon.2014.04.008 CrossRefPubMedGoogle Scholar
- 28.Kampshoff CS, van Dongen JM, van Mechelen W, Schep G, Vreugdenhil A, Twisk JWR, Bosmans JE, Brug J, Chinapaw MJM, Buffart LM (2018) Long-term effectiveness and cost-effectiveness of high versus low-to-moderate intensity resistance and endurance exercise interventions among cancer survivors. J Cancer Surviv Res Pract 12:417–429. https://doi.org/10.1007/s11764-018-0681-0 CrossRefGoogle Scholar
- 29.Mewes JC, Steuten LMG, Duijts SFA, Oldenburg HS, van Beurden M, Stuiver MM, Hunter MS, Kieffer JM, van Harten W, Aaronson NK (2015) Cost-effectiveness of cognitive behavioral therapy and physical exercise for alleviating treatment-induced menopausal symptoms in breast cancer patients. J Cancer Surviv 9:126–135. https://doi.org/10.1007/s11764-014-0396-9 CrossRefPubMedGoogle Scholar
- 30.May AM, Bosch MJC, Velthuis MJ, van der Wall E, Steins Bisschop CN, Los M, Erdkamp F, Bloemendal HJ, de Roos MA, Verhaar M, ten Bokkel Huinink D, Peeters PH, de Wit GA (2017) Cost-effectiveness analysis of an 18-week exercise programme for patients with breast and colon cancer undergoing adjuvant chemotherapy: the randomised PACT study. BMJ Open 7:e012187. https://doi.org/10.1136/bmjopen-2016-012187 CrossRefPubMedPubMedCentralGoogle Scholar
- 31.Gordon LG, DiSipio T, Battistutta D, Yates P, Bashford J, Pyke C, Eakin E, Hayes SC (2017) Cost-effectiveness of a pragmatic exercise intervention for women with breast cancer: results from a randomized controlled trial. Psychooncology 26:649–655. https://doi.org/10.1002/pon.4201 CrossRefPubMedGoogle Scholar
- 32.van de Wiel HJ, Stuiver MM, May AM et al (2018) (Cost-)effectiveness of an internet-based physical activity support program (with and without physiotherapy counseling) on physical activity levels of breast and prostate cancer survivors: design of the PABLO trial. BMC Cancer 18:1073. https://doi.org/10.1186/s12885-018-4927-z CrossRefPubMedPubMedCentralGoogle Scholar
- 34.Gray AM, Clarke PM, Wolstenholme JL, Wordsworth S (2010) Applied methods of cost-effectiveness analysis in healthcare. Oxford University Press, OxfordGoogle Scholar
- 37.Short CE, James EL, Girgis A, McElduff P, Plotnikoff RC (2012) Move more for life: the protocol for a randomised efficacy trial of a tailored-print physical activity intervention for post-treatment breast cancer survivors. BMC Cancer 12:172. https://doi.org/10.1186/1471-2407-12-172 CrossRefPubMedPubMedCentralGoogle Scholar
- 39.Carayol M, Romieu G, Bleuse J-P, Senesse P, Gourgou-Bourgade S, Sari C, Jacot W, Sancho-Garnier H, Janiszewski C, Launay S, Cousson-Gélie F, Ninot G (2013) Adapted physical activity and diet (APAD) during adjuvant breast cancer therapy: design and implementation of a prospective randomized controlled trial. Contemp Clin Trials 36:531–543. https://doi.org/10.1016/j.cct.2013.09.016 CrossRefPubMedGoogle Scholar