Skip to main content
SpringerLink
Log in

Using Cost-Effectiveness Analysis to Define a Breast Cancer Benefits Package for the Uninsured

  • Published:
Breast Cancer Research and Treatment Aims and scope Submit manuscript

Abstract

Objectives. In 1999, California was considering legislation to fund breast cancer treatment for its uninsured. We sought to define the most cost-effective breast cancer benefits package in order to inform this debate.

Methods. We use cost-effectiveness analysis to calculate the additional costs and benefits of various adjuvant therapy strategies, radiation after breast conserving surgery, and reconstruction compared to those of surgery alone in order to define the most cost-effective breast cancer benefits package for uninsured women.

Results. Using cost-effectiveness analysis, we define a Minimum Breast Cancer Benefits Package that includes only the most cost-effective life-saving breast cancer treatments. To provide these benefits for an estimated 550 breast cancer patients will cost $10,200,000. We present two options that each cost an additional $1,700,000 – to expand the benefits to these patients to include post-mastectomy radiation and breast reconstruction; or to provide the Minimum Package to an additional 93 uninsured women.

Conclusions. California legislators must decide whether to offer comprehensive benefits to a limited number of breast cancer patients or to provide only the most life-saving treatments to a greater number of women.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Bennefield RL: Health Insurance Coverage: 1997. Current Population Reports. Current Population Survey. U.S. Census Bureau, Washington, DC, 1998

    Google Scholar 

  2. Cunningham PJ, Kemper P: Ability to obtain medical care for the uninsured: how much does it vary across communities? JAMA 280: 921–927, 1998

    PubMed  Google Scholar 

  3. Morbidity and Mortality Weekly Report: Strategies for provid-ing follow-up and treatment services in the National Breast and Cervical Cancer Early Detection Program-United States, 1997. MMWR 47: 215, 1998

    Google Scholar 

  4. Personal Communication: Gita Mahendra, Cancer Detection Section, Department of Health Service, Sacramento, Califor-nia, July 22, 1999

  5. Health Line, 3–22-99: Available at www.californiahealthline.org. Accessed December 12, 2000

  6. Gold MR, Siegel JE, Russell LB, Weinstein MC (eds): Cost-Effectiveness in Health and Medicine. Oxford University Press, New York, NY, 1996

    Google Scholar 

  7. Early Breast Cancer Trialists' Collaborative Group: Tamox-ifen for early breast cancer: An overview of the randomised trials. Lancet 351(9114): 1451–1467, 1998

    Google Scholar 

  8. Early Breast Cancer Trialists' Collaborative Group: Poly chemotherapy for early breast cancer: An overview of the randomised trials. Lancet 352: 930–942, 1998

    Google Scholar 

  9. Keeler E, Bell R: New DEALES: Other approximations of life expectancy. Med Decision Making 12: 307–311, 1992

    Google Scholar 

  10. Vital Statistics of the United States, 1992: Hyattsville, MD: National Center for Health Statistics, 1992

  11. Hillner BE, Smith TJ: Efficacy and cost effectiveness of ad-juvant chemotherapy in women with node-negative breast cancer. N Engl J Med 324: 160–168, 1991

    PubMed  Google Scholar 

  12. Early Breast Cancer Trialists' Collaborative Group: Effects of radiotherapy and surgery in early breast cancer: An overview of the randomized trials. N Engl J Med 333(22): 1444–1455, 1995

    Google Scholar 

  13. De Haes JCMJM, van Ostrom MA, Welvaart K: The effect of radical and conserving surgery on the QoL of early breast cancer patients. Euro J Surg Oncol 12: 337–342, 1986

    Google Scholar 

  14. Kemeny MM, Wellisch DK, Schain WS: Psychosocial out-come in a randomized surgical trial for treatment of primary breast cancer. Cancer 62: 1231–1237, 1988

    PubMed  Google Scholar 

  15. Wellisch DK, DiMatteo R, Silverstein M, Landsverk J, Hoffman R, Waisman J, Handel N, Waisman-Smith E, Schain W: Psychosocial outcomes of breast cancer therapies: Lumpectomy versus mastectomy. Psychosomatics 30: 365–373, 1989

    PubMed  Google Scholar 

  16. Leinster SJ, Ashcroft JJ, Slade PD, Dewey ME. Mastectomy versus conservative surgery: Psychosocial effects of the pa-tient's choice of treatment. J Psychosoc Oncol 7: 179–192, 1989.

    Google Scholar 

  17. Fisher B, Dignam J, Wolmark N, DeCillis A, Emir B, Wickerham DL, Bryant J, Dimitrov NV, Abramson N, Atkins JN, Shibata H, Deschenes L, Margolese RG: Tamoxifen and chemotherapy for lymph node-negative, estrogen receptor-positive breast cancer J Natl Cancer Inst 89: 1673–1682, 1997

    Google Scholar 

  18. International Breast Cancer Study Group: Effectiveness of adjuvant chemotherapy in combination with tamoxifen for node-positive postmenopausal breast cancer patients. J Clin Oncol 15: 1385–1394, 1997

    Google Scholar 

  19. Fisher B, Wickerham DL, Deutsch M, Anderson S, Redmond C, Fisher ER: Breast tumor recurrence following lumpectomy with and without breast irradiation: An overview of recent NSABP findings. Semin Surg Oncol 8: 53–160, 1992

    Google Scholar 

  20. Overgaard M, Hansen PS, Overgaard J, Rose C, Andersson M, Bach F, Kjaer M, Gadeberg CC, Mouridsen HT, Jensen MB, Xedeler K: Postoperative radiotherapy in high-risk premenopausal women with breast cancer who re-ceive adjuvant chemotherapy. N Engl J Med 337: 949–955, 1997

    PubMed  Google Scholar 

  21. Recht A, Gray R, Davidson NE, Fowble BL, Solin LJ, Cum-mings FJ, Falkson G, Falkson HC, Taylor SG 4th, Tormey DC: Locoregional failure at 10 years after mastectomy and adjuvant chemotherapy with or without tamoxifen without irradiation: Experience of the Eastern Cooperative Oncology Group. J Clin Oncol 17: 1689–1700, 1999

    PubMed  Google Scholar 

  22. Reaby LL, Hort LK: Postmastectomy attitudes in women who wear external breast prostheses compared to those who have undergone breast reconstructions. J Behav Med18: 55–67, 1995

    PubMed  Google Scholar 

  23. Grunfeld E, Mant D, Yudkin P, Adewuyi-Dalton R, Cole D, Stewart J, Fitzpatrick R, Vessey M: Routine follow up of breast cancer in primary care: Randomized trial. BMJ 313: 665–669, 1996

    PubMed  Google Scholar 

  24. Delay E, Jorquera F, Pasi P, Gratadour AC: Autologous latis-simus breast reconstruction in association with the abdominal advancement flap: A new refinement in breast reconstruction. Ann Plastic Surg 42: 67–75, 1999

    Google Scholar 

  25. Kroll SS, Schusterman MA, Reece GP, Miller MJ, Smith B: Breast reconstruction with myocutaneous flaps in previously irradiated patients. Plastic Reconstruct Surg. 93: 460–469, 1994

    Google Scholar 

  26. Fisher B, Brown AM, Dimitrov NV, Poisson R, Redmond C, Margolese RG, Bowman D, Wolmark N, Wickerham DL, Kardinal CG: Two months of doxorubicin and cyclophosph-amide with and without interval reinduction therapy compared with 6 months of cyclophosphamide, methotrexate, and fluor-ouracil in positive-node breast cancer patients with tamoxifen-nonresponsive tumors: Results from the National Surgical Adjuvant Bowel and Breast Project B-15. J Clin Oncol 8: 1483–1496, 1990

    PubMed  Google Scholar 

  27. Smith TJ, Davidson NE, Schapira DV, Grunfeld E, Muss HB, Vogel 3rd VG, Somerfield MR: American Society of Clinical Oncology 1998 update of recommended breast can-cer surveillance guidelines. J Clin Oncol 17: 1080–1082, 1999

    PubMed  Google Scholar 

  28. GIVIO Investigators: Impact of follow-up testing on survival and health-related QoL in breast cancer patients: A multi-center randomized controlled trial. JAMA 271: 1587–1592, 1994

    Google Scholar 

  29. Del Turco MR, Palli D, Cariddi A, Ciatto S, Pacini P, Distante V: Intensive diagnostic follow-up after treatment of primary breast cancer: A randomized trial. JAMA 271: 1593–1597, 1994

    PubMed  Google Scholar 

  30. Baldwin AL, Holliman R, Semmens WJ: Actuarial analysis of the California Breast Cancer Treatment Fund. California Health Care Foundation, 2000

  31. Hayman JA, Hillner BE, Harris JR, Weeks JC: Cost-effect-iveness of routine radiation therapy following conservative surgery for early-stage breast cancer. J Clin Oncol 16: 1022–1029, 1998

    PubMed  Google Scholar 

  32. Scitovsky AA: 'The high cost of dying' revisited. Milbank Quart 72: 561–591, 1994

    Google Scholar 

  33. Nemoto T, Vana J, Bedwani RN, Baker HW, McGregor FH, Murphy GP: Management and survival of female breast can-cer: Results of a national survey by the American College of Surgeons. Cancer 45: 2917, 1980

    PubMed  Google Scholar 

  34. Morris CR: Surgical Treatment of Female Breast Cancer, 1988–1992. Breast Cancer in California. Department of Health Services, Sacramento, CA, 1996

    Google Scholar 

  35. Public Law 105–277, 1998: Available at: http://thomas.loc. gov/bss/d105query.html. Accessed December 12, 2000

  36. Zhang J, Yu KF: What's the relative risk? A method of cor-recting the odds ratio in cohort studies of common outcomes. JAMA 280: 1690–1691, 1998

    PubMed  Google Scholar 

  37. Personal Communication: Gita Mahendra. Department of Health Service, Sacramento, CA: Cancer Detection Section, 1999

  38. Nord E: The tradeoff between severity of illness and treatment effect in cost-value analysis of health care. Health Policy 24: 227–238, 1993

    PubMed  Google Scholar 

  39. Baldwin AL, Holliman R, Semmens WJ: Actuarial analysis of the California Breast Cancer Treatment Fund. California Health Care Foundation, 2000

  40. Brown M, Fintor L: Cost-effectiveness of breast cancer screen-ing: Preliminary results of a systematic review of the literature. Breast Cancer Res Treat 8: 113–118, 1993

    Google Scholar 

  41. Desch CE, Hillner BE, Smith TJ, Retchin SM: Should the elderly receive chemotherapy for node-negative breast cancer? A cost-effectiveness analysis for examining total and active life-expectancy outcomes. J Clin Oncol 11: 777–782, 1993

    PubMed  Google Scholar 

  42. Smith TJ, Hillner BE. The efficacy and cost-effectiveness of adjuvant therapy of early breast cancer in premenopausal women. J Clin Oncol 11: 771–776, 1993

    PubMed  Google Scholar 

  43. Carter CL, Allen C, Henson DE: Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer 63: 181–187, 1989

    PubMed  Google Scholar 

  44. Relative Survival of Breast Cancer Patients by AJCC Stage of Disease at Diagnosis: National Cancer Data Base, 1985–1990

Download references

Author information

Authors and Affiliations

  1. Department of Medicine, University of California, Los Angeles

    Jennifer L. Malin & Robert Brook

  2. RAND, Santa Monica, CA, USA

    Jennifer L. Malin, Emmett Keeler, Cynthia Wang & Robert Brook

Authors
  1. Jennifer L. Malin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Emmett Keeler
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Cynthia Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Robert Brook
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Malin, J.L., Keeler, E., Wang, C. et al. Using Cost-Effectiveness Analysis to Define a Breast Cancer Benefits Package for the Uninsured. Breast Cancer Res Treat 74, 143–153 (2002). https://doi.org/10.1023/A:1016140228720

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1023/A:1016140228720

Search

Navigation