Breast Cancer Research and Treatment

, Volume 136, Issue 2, pp 547–557 | Cite as

Economic evaluation of radiotherapy for early breast cancer after breast-conserving surgery in a health resource-limited setting

  • Yongrui Bai
  • Ming Ye
  • Hongbin Cao
  • Xiumei Ma
  • Yuejuan Xu
  • Bin Wu
Epidemiology

Abstract

The primary objective was to assess the cost-effectiveness, from the Chinese societal perspective, of additional radiotherapy for women with early breast cancer after breast-conserving surgery (BCS). The Markov model was constructed to simulate women’s transitions across various health states based on the clinical course of breast cancer (no recurrence, local or distant recurrence, and death) and treatment strategy (radiotherapy vs. no-radiotherapy). The clinical and utility data were estimated from published studies. Costs were estimated from the perspective of Chinese society. Quality-adjusted life-years (QALYs) and incremental cost-effective ratios (ICERs) were determined. Probabilistic and one-way sensitivity analyses were performed. The addition of radiotherapy following BCS was associated with improved overall survival (22.20 vs. 19.51 years) and QALYs (13.25 vs. 11.75) and reduced lifetime costs ($24,518.9 vs. $25,147.0). The ICER of radiotherapy vs. no-radiotherapy was −$420.56/QALY gained. Sensitivity, subgroup and scenario analyses indicated that these results were robust against plausible assumptions and variations. In health resource-limited settings, the addition of radiotherapy is a very cost-effective strategy in comparison to no-radiotherapy in women with early breast cancer.

Keywords

Early breast cancer Cost-effectiveness Markov model Radiotherapy 

Notes

Acknowledgments

This study was supported by a grant from Shanghai Jiaotong University School of Medicine (no. 2011.18).

Conflict of interest

The authors declared no conflict of interest.

References

  1. 1.
    Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D (2011) Global cancer statistics. CA Cancer J Clin 61:69–90PubMedCrossRefGoogle Scholar
  2. 2.
    Porter PL (2009) Global trends in breast cancer incidence and mortality. Salud Publica Mex 51(Suppl 2):s141–s146PubMedCrossRefGoogle Scholar
  3. 3.
    Chen JG, Zhu J, Parkin DM, Zhang YH, Lu JH, Zhu YR et al (2006) Trends in the incidence of cancer in Qidong, China, 1978–2002. Int J Cancer 119:1447–1454PubMedCrossRefGoogle Scholar
  4. 4.
    Linos E, Spanos D, Rosner BA, Linos K, Hesketh T, Qu JD et al (2008) Effects of reproductive and demographic changes on breast cancer incidence in China: a modeling analysis. J Natl Cancer Inst 100:1352–1360PubMedCrossRefGoogle Scholar
  5. 5.
    Jin F, Devesa SS, Chow WH, Zheng W, Ji BT, Fraumeni JF Jr et al (1999) Cancer incidence trends in urban shanghai, 1972–1994: an update. Int J Cancer 83:435–440PubMedCrossRefGoogle Scholar
  6. 6.
    Albert US, Altland H, Duda V, Engel J, Geraedts M, Heywang-Kobrunner S et al (2009) 2008 Update of the guideline: early detection of breast cancer in Germany. J Cancer Res Clin Oncol 135:339–354PubMedCrossRefGoogle Scholar
  7. 7.
    Wang K, Wu Y, Zheng D, Liao N (2005) NCCN breast cancer practice guidelines. J Evid Based Med 5:232–256Google Scholar
  8. 8.
    Fitzal F, Riedl O, Jakesz R (2009) Recent developments in breast-conserving surgery for breast cancer patients. Langenbecks Arch Surg 394:591–609PubMedCrossRefGoogle Scholar
  9. 9.
    Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A et al (2002) Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 347:1227–1232PubMedCrossRefGoogle Scholar
  10. 10.
    Zielske SP, Spalding AC, Wicha MS, Lawrence TS (2011) Ablation of breast cancer stem cells with radiation. Transl Oncol 4:227–233PubMedGoogle Scholar
  11. 11.
    Lim M, Bellon JR, Gelman R, Silver B, Recht A, Schnitt SJ et al (2006) A prospective study of conservative surgery without radiation therapy in select patients with Stage I breast cancer. Int J Radiat Oncol Biol Phys 65:1149–1154PubMedCrossRefGoogle Scholar
  12. 12.
    Abe O, Abe R, Asaishi K, Enomoto K, Hattori T, Iino Y et al (1995) Effects of radiotherapy and surgery in early breast-cancer—an overview of the randomized trials. N Engl J Med 333:1444–1455CrossRefGoogle Scholar
  13. 13.
    Bartelink H, Horiot JC, Poortmans PM, Struikmans H, Van den Bogaert W, Fourquet A et al (2007) Impact of a higher radiation dose on local control and survival in breast-conserving therapy of early breast cancer: 10-year results of the randomized boost versus no boost EORTC 22881–10882 trial. J Clin Oncol 25:3259–3265PubMedCrossRefGoogle Scholar
  14. 14.
    Fisher B, Bryant J, Dignam JJ, Wickerham DL, Mamounas EP, Fisher ER et al (2002) Tamoxifen, radiation therapy, or both for prevention of ipsilateral breast tumor recurrence after lumpectomy in women with invasive breast cancers of one centimeter or less. J Clin Oncol 20:4141–4149PubMedCrossRefGoogle Scholar
  15. 15.
    Forrest AP, Stewart HJ, Everington D, Prescott RJ, McArdle CS, Harnett AN et al (1996) Randomised controlled trial of conservation therapy for breast cancer: 6-year analysis of the Scottish trial. Lancet (North American Edition) 348:708–713CrossRefGoogle Scholar
  16. 16.
    Fyles AW, McCready DR, Manchul LA, Trudeau ME, Merante P, Pintilie M et al (2004) Tamoxifen with or without breast irradiation in women 50 years of age or older with early breast cancer. N Engl J Med 351:963–970PubMedCrossRefGoogle Scholar
  17. 17.
    Hughes KS, Schnaper LA, Berry D, Cirrincione C, McCormick B, Shank B et al (2004) Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 351:971–977PubMedCrossRefGoogle Scholar
  18. 18.
    Liljegren G, Holmberg L, Adami HO, Westman G, Graffman S, Bergh J et al (1994) Sector resection with or without postoperative radiotherapy for stage I breast cancer: five-year results of a randomized trial. J Natl Cancer Inst (Bethesda) 86:717–722CrossRefGoogle Scholar
  19. 19.
    Malmstrom P, Holmberg L, Anderson H, Mattsson J, Jonsson PE, Tennvall-Nittby L et al (2003) Breast conservation surgery, with and without radiotherapy, in women with lymph node-negative breast cancer: a randomised clinical trial in a population with access to public mammography screening. Eur J Cancer 39:1690–1697PubMedCrossRefGoogle Scholar
  20. 20.
    Potter R, Gnant M, Kwasny W, Tausch C, Handl-Zeller L, Pakisch B et al (2007) Lumpectomy plus tamoxifen or anastrozole with or without whole breast irradiation in women with favorable early breast cancer. Int J Radiat Oncol Biol Phys 68:334–340PubMedCrossRefGoogle Scholar
  21. 21.
    Romestaing P, Lehingue Y, Carrie C, Coquard R, Montbarbon X, Ardiet JM et al (1997) Role of a 10-Gy boost in the conservative treatment of early breast cancer: results of a randomized clinical trial in Lyon, France. J Clin Oncol 15:963–968PubMedGoogle Scholar
  22. 22.
    Veronesi U, Luini A, Del Vecchio M, Greco M, Galimberti V, Merson M et al (1993) Radiotherapy after breast-preserving surgery in women with localized cancer of the breast. N Engl J Med 328:1587–1591PubMedCrossRefGoogle Scholar
  23. 23.
    Darby S, McGale P, Correa C, Taylor C, Arriagada R, Clarke M et al (2011) Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 378:1707–1716PubMedCrossRefGoogle Scholar
  24. 24.
    Bellon JR, Harris EE, Arthur DW, Bailey L, Carey L, Goyal S et al (2011) ACR appropriateness criteria(R) conservative surgery and radiation–stage I and II breast carcinoma: expert panel on radiation oncology: breast. Breast J 17:448–455PubMedCrossRefGoogle Scholar
  25. 25.
    Hayman JA, Hillner BE, Harris JR, Weeks JC (1998) Cost-effectiveness of routine radiation therapy following conservative surgery for early-stage breast cancer. J Clin Oncol 16:1022–1029PubMedGoogle Scholar
  26. 26.
    Liljegren G, Karlsson G, Bergh J, Holmberg L (1997) The cost-effectiveness of routine postoperative radiotherapy after sector resection and axillary dissection for breast cancer stage I. Results from a randomized trial. Ann Oncol 8:757–763PubMedCrossRefGoogle Scholar
  27. 27.
    Suh WW, Hillner BE, Pierce LJ, Hayman JA (2005) Cost-effectiveness of radiation therapy following conservative surgery for ductal carcinoma in situ of the breast. Int J Radiat Oncol Biol Phys 61:1054–1061PubMedCrossRefGoogle Scholar
  28. 28.
    Anderson BO, Shyyan R, Eniu A, Smith RA, Yip CH, Bese NS et al (2006) Breast cancer in limited-resource countries: an overview of the Breast Health Global Initiative 2005 guidelines. Breast J 12(Suppl 1):S3–S15PubMedCrossRefGoogle Scholar
  29. 29.
    Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) (2005) Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 365:1687-1717Google Scholar
  30. 30.
    Suen D, Chow L, Kwong A (2008) Breast-conserving surgery in Hong Kong Chinese women. World J Surg 32:2549–2553PubMedCrossRefGoogle Scholar
  31. 31.
    Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J, Ewigman B et al (2004) Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 69:548–556PubMedGoogle Scholar
  32. 32.
    Wilson DL (1994) The analysis of survival (mortality) data: fitting Gompertz, Weibull, and logistic functions. Mech Ageing Dev 74:15–33PubMedCrossRefGoogle Scholar
  33. 33.
    Schmoor C, Sauerbrei W, Bastert G, Schumacher M (2000) Role of isolated locoregional recurrence of breast cancer: results of four prospective studies. J Clin Oncol 18:1696–1708PubMedGoogle Scholar
  34. 34.
    Rau KM, Li SH, Chen SM, Tang Y, Huang CH, Wu SC et al (2011) Weekly paclitaxel combining with gemcitabine is an effective and safe treatment for advanced breast cancer patients. Jpn J Clin Oncol 41:455–461PubMedCrossRefGoogle Scholar
  35. 35.
    Fan Y, Xu B, Yuan P, Wang J, Ma F, Li Q et al (2010) Prospective study of vinorelbine and capecitabine combination therapy in Chinese patients with metastatic breast cancer pretreated with anthracyclines and taxanes. Chemotherapy 56:340–347PubMedCrossRefGoogle Scholar
  36. 36.
    Yeo W, Mok TS, Tse KK, Kwan WH, Lam KC, Ho WM et al (2002) Phase II study of docetaxel and epirubicin in Chinese patients with metastatic breast cancer. Anticancer Drugs 13:655–662PubMedCrossRefGoogle Scholar
  37. 37.
    Yeh KH, Lu YS, Hsu CH, Lin JF, Chao HJ, Huang TC et al (2005) Phase II study of weekly vinorelbine and 24-h infusion of high-dose 5-fluorouracil plus leucovorin as first-line treatment of advanced breast cancer. Br J Cancer 92:1013–1018PubMedCrossRefGoogle Scholar
  38. 38.
    Lin YC, Chang HK, Chen JS, Wang HM, Yang TS, Liaw CC (2007) A phase II randomized study of two taxanes and cisplatin for metastatic breast cancer after anthracycline: a final analysis. Jpn J Clin Oncol 37:23–29PubMedCrossRefGoogle Scholar
  39. 39.
    Life tables for WHO Member States (2011) World Health Organization, Geneva. http://www.who.int/whosis/database/life_tables/life_tables.cfm. Accessed 12 Mar 2012
  40. 40.
    Liubao P, Xiaomin W, Chongqing T, Karnon J, Gannong C, Jianhe L et al (2009) Cost-effectiveness analysis of adjuvant therapy for operable breast cancer from a Chinese perspective: doxorubicin plus cyclophosphamide versus docetaxel plus cyclophosphamide. Pharmacoeconomics 27:873–886PubMedCrossRefGoogle Scholar
  41. 41.
    Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB (1996) Recommendations of the panel on cost-effectiveness in health and medicine. JAMA 276:1253–1258PubMedCrossRefGoogle Scholar
  42. 42.
    Lidgren M, Wilking N, Jonsson B, Rehnberg C (2007) Health related quality of life in different states of breast cancer. Qual Life Res 16:1073–1081PubMedCrossRefGoogle Scholar
  43. 43.
    Ward S, Simpson E, Davis S, Hind D, Rees A, Wilkinson A (2007) Taxanes for the adjuvant treatment of early breast cancer: systematic review and economic evaluation. Health Technol Assess 11:1–144Google Scholar
  44. 44.
    Bruno R, Galastri S, Sacchi P, Cima S, Caligiuri A, DeFranco R et al (2010) gp120 Modulates the biology of human hepatic stellate cells: a link between HIV infection and liver fibrogenesis. Gut 59:513–520PubMedCrossRefGoogle Scholar
  45. 45.
    Eichler HG, Kong SX, Gerth WC, Mavros P, Jonsson B (2004) Use of cost-effectiveness analysis in health-care resource allocation decision-making: how are cost-effectiveness thresholds expected to emerge? Value Health 7:518–528PubMedCrossRefGoogle Scholar
  46. 46.
    Murray CJ, Evans DB, Acharya A, Baltussen RM (2000) Development of WHO guidelines on generalized cost-effectiveness analysis. Health Econ 9:235–251PubMedCrossRefGoogle Scholar
  47. 47.
    Li J, Zhang BN, Fan JH, Pang Y, Zhang P, Wang SL et al (2011) A nation-wide multicenter 10-year (1999–2008) retrospective clinical epidemiological study of female breast cancer in China. BMC Cancer 11:364PubMedCrossRefGoogle Scholar
  48. 48.
    Lee JH, Glick HA, Hayman JA, Solin LJ (2002) Decision-analytic model and cost-effectiveness evaluation of postmastectomy radiation therapy in high-risk premenopausal breast cancer patients. J Clin Oncol 20:2713–2725PubMedCrossRefGoogle Scholar
  49. 49.
    Osteen RT, Karnell LH (1994) The National Cancer Data Base report on breast cancer. Cancer 73:1994–2000PubMedCrossRefGoogle Scholar
  50. 50.
    Untch M (2011) Treatment of early breast cancer. Breast Care (Basel) 6:177CrossRefGoogle Scholar
  51. 51.
    Lee SG, Jee YG, Chung HC, Kim SB, Ro J, Im YH et al (2009) Cost-effectiveness analysis of adjuvant therapy for node positive breast cancer in Korea: docetaxel, doxorubicin and cyclophosphamide (TAC) versus fluorouracil, doxorubicin and cyclophosphamide (FAC). Breast Cancer Res Treat 114:589–595PubMedCrossRefGoogle Scholar
  52. 52.
    Sculpher M (2008) Subgroups and heterogeneity in cost-effectiveness analysis. Pharmacoeconomics 26:799–806PubMedCrossRefGoogle Scholar
  53. 53.
    Delaney G (2005) Recent advances in the use of radiotherapy to treat early breast cancer. Curr Opin Obstet Gynecol 17:27–33PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Yongrui Bai
    • 1
  • Ming Ye
    • 2
  • Hongbin Cao
    • 1
  • Xiumei Ma
    • 1
  • Yuejuan Xu
    • 3
  • Bin Wu
    • 4
  1. 1.Department of RadiotherapyRenji Hospital, Affiliated with the School of Medicine, Shanghai Jiaotong UniversityShanghaiChina
  2. 2.Department of Clinical OncologyRenji Hospital, Affiliated with the School of Medicine, Shanghai Jiaotong UniversityShanghaiChina
  3. 3.Department of Clinical OncologyThe Second Hospital of Nanjing, Affiliated with the Medical School of South East UniversityNanjingChina
  4. 4.Clinical Outcomes and Economics Group, Department of PharmacyRenji Hospital, Affiliated with the School of Medicine, Shanghai Jiaotong UniversityShanghaiChina

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