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Cost-effectiveness analyses demonstrate that observation is superior to sentinel lymph node biopsy for postmenopausal women with HR + breast cancer and negative axillary ultrasound

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Abstract

Purpose

To evaluate the cost-effectiveness of axillary observation versus sentinel lymph node biopsy (SLNB) after negative axillary ultrasound (AUS). In patients with clinical T1-T2 N0 breast cancer and negative AUS, SLNB is the current standard of care for axillary staging. However, SLNB is costly, invasive, decreasing in importance for medical decision-making, and is not considered therapeutic. Observation alone is currently being evaluated in randomized clinical trials, and is thought to be non-inferior to SLNB for patients with negative AUS.

Methods

We performed cost-effectiveness analyses of observation versus SLNB after negative AUS in postmenopausal women with clinical T1-T2 N0, HR+/HER2− breast cancer. Costs at the 2016 price level were evaluated from a third-party commercial payer perspective using the MarketScan® Database. We compared cost, quality-adjusted life years (QALYs), and net monetary benefit (NMB). Multiple sensitivity analyses varying baseline probabilities, costs, utilities, and willingness-to-pay thresholds were performed.

Results

Observation was superior to SLNB for patients with N0 and N1 disease, and for the entire patient population (NMB in US$: $655,659 for observation versus $641,778 for SLNB for the entire patient population). In the N0 and N1 groups, observation incurred lower cost and was associated with greater QALYs. SLNB was superior for patients with > 3 positive lymph nodes, representing approximately 5% of the population. Sensitivity analyses consistently demonstrated that observation is the optimal strategy for AUS-negative patients.

Conclusion

Considering both cost and effectiveness, observation is superior to SLNB in postmenopausal women with cT1-T2 N0, HR+/HER2− breast cancer and negative AUS.

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Acknowledgements

We thank Laura Simon and the Washington University, St. Louis Bernard Becker Library for systematic review assistance. We thank the Siteman Cancer Center for supporting breast oncology investigation. Research reported in this publication was supported by the Washington University Institute of Clinical and Translational Sciences grant UL1TR002345 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health, and National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number TL1TR002344. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The Center for Administrative Data Research is supported in part by the Washington University Institute of Clinical and Translational Sciences grant UL1TR002345 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH) and Grant Number R24 HS19455 through the Agency for Healthcare Research and Quality (AHRQ).

Funding

UL1TR002345: National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health. TL1TR002344: National Center for Advancing Translational Sciences of the National Institutes of Health. This study was not supported, in any way, by a pharmaceutical company. This study was funded by the National Center for Advancing Translational Sciences via grant #UL1TR002345 supporting Dr. Steven Poplack, and Grant #TL1TR002344 supporting Aubriana McEvoy.

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Authors and Affiliations

  1. Department of Surgery, Section of Endocrine and Oncologic Surgery, Washington University St. Louis, St. Louis, MO, USA

    Aubriana M. McEvoy, Jennifer Yu & William E. Gillanders

  2. School of Medicine, University of Washington, Seattle, WA, USA

    Aubriana M. McEvoy

  3. Department of Diagnostic Radiology, Section of Breast Imaging, Washington, University St. Louis, St. Louis, MO, USA

    Steven Poplack

  4. Siteman Cancer Center, St. Louis, MO, USA

    Steven Poplack, Margaret A. Olsen, Foluso Ademuyiwa, Imran Zoberi, Su-Hsin Chang & William E. Gillanders

  5. Division of Infectious Diseases, Center for Administrative Data Research, Washington University St. Louis, St. Louis, MO, USA

    Katelin Nickel & Margaret A. Olsen

  6. Department of Surgery, Division of Public Health Science, Washington University St. Louis, St. Louis, MO, USA

    Margaret A. Olsen & Su-Hsin Chang

  7. Department of Medical Oncology, Washington, University St. Louis, St. Louis, MO, USA

    Foluso Ademuyiwa

  8. Department of Radiation Oncology, Washington, University St. Louis, St. Louis, MO, USA

    Imran Zoberi

  9. Division of Plastic Surgery, Washington, University St. Louis, St. Louis, MO, USA

    Elizabeth Odom

  10. Department of Surgery, Washington University School of Medicine, Campus Box 8109, 4590 Children’s Place, Suite 9600, St. Louis, MO, 63110, USA

    William E. Gillanders

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  1. Aubriana M. McEvoy
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  2. Steven Poplack
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  3. Katelin Nickel
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  8. Jennifer Yu
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  9. Su-Hsin Chang
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  10. William E. Gillanders
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Correspondence to William E. Gillanders.

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All authors (Aubriana McEvoy, Steven Poplack, Katelin Nickel, Margaret Olsen, Foluso Ademuyiwa, Imran Zoberi, Elizabeth Odom, Jennifer Yu, Su-Hsin Chang, and William Gillanders) have no conflict of interest.

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McEvoy, A.M., Poplack, S., Nickel, K. et al. Cost-effectiveness analyses demonstrate that observation is superior to sentinel lymph node biopsy for postmenopausal women with HR + breast cancer and negative axillary ultrasound. Breast Cancer Res Treat 183, 251–262 (2020). https://doi.org/10.1007/s10549-020-05768-2

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