Performance Goals for an Adjunct Diagnostic Test to Reduce Unnecessary Biopsies After Screening Mammography: Analysis of Costs, Benefits, and Consequences

Rising drug cost impacts on cost-effectiveness of 2 chemotherapy regimens for intermediate-risk rhabdomyosarcoma: A report from the Children's Oncology Group

BACKGROUND

The Children's Oncology Group clinical trial for intermediate risk rhabdomyosarcoma randomized participants to a combination of vincristine, dactinomycin, and cyclophosphamide (VAC) alone or VAC alternating with vincristine plus irinotecan (VAC/VI). Clinical outcomes were similar, but toxicity profiles differed. This study estimates the cost differences between arms from the health care system's perspective.

METHODS

A decision-analytic model was used to estimate the incremental cost-effectiveness ratio (ICER) of VAC versus VAC/VI. Protocol-required or recommended medications and laboratory studies were included. Costs were obtained from national databases or supporting literature and inflated to 2019 US dollars. Demographic and outcome data were obtained from the clinical trial and directed chart reviews. Life-years (LY) were estimated from life-expectancy tables and discounted by 3% annually. Probabilistic sensitivity analyses and alternative clinical scenarios identified factors driving costs.

RESULTS

Mean direct medical costs of VAC and VAC/VI were $164,757 and $102,303, respectively. VAC was associated with an additional 0.97 LY and an ICER of $64,386/LY compared with VAC/VI. The ICER was sensitive to survival estimations and to alternative clinical scenarios including outpatient cyclophosphamide delivery (ICER $49,037/LY) or substitution of alternative hematopoietic growth factor schedules (ICER $73,191-$91,579/LY). Applying drug prices from 2012 decreased the total costs of VAC by 20% and VAC/VI by 15% because of changes in dactinomycin and pegfilgrastim prices.

CONCLUSIONS

Neither arm was clearly more cost-effective. Pharmaceutical pricing and location of treatment drove costs and may inform future treatment decisions. Rising pharmaceutical costs added $30,000 per patient, a finding important for future drug-pricing policy decisions.

LAY SUMMARY

Two chemotherapy regimens recently tested side-by-side for rhabdomyosarcoma had similar tumor outcomes, but different side effects. The health care costs of each regimen were compared; neither was clearly more cost-effective. However, the costs of each treatment changed dramatically with choices of supportive medicines and location of treatment. Costs of treatment rose by 15% to 20% because of rising US drug costs not associated with the clinical trial.

The Clinical Utility of a Negative Result at Molecular Breast Imaging: Initial Proof of Concept

Purpose

To calculate the negative predictive value (NPV) and false-negative rate (FNR) of molecular breast imaging (MBI) performed in patients who had low-suspicion index findings on mammograms and US images.

Materials and Methods

This retrospective study included patients who had undergone MBI between January 2015 and July 2017, who had index findings on screening mammograms and/or US images, and for whom either histopathologic results or a minimum of 1-year imaging follow-up results were available. A drawn dose of 8 mCi (296 MBq) of technetium 99m sestamibi was administered to all patients for MBI. The NPV and FNR of MBI was calculated for the cohort of 381 findings among 338 women (median age, 56 years; age range, 28-89 years) included in this study.

Results

Overall, 292 of the 381 (76.6%) MBI results were interpreted as negative. Of the 292, 27 patients underwent subsequent biopsies, results of which were negative for cancer; one patient underwent biopsy, and the result was positive for cancer; and 264 patients had true-negative findings based on follow-up imaging for a minimum of 1 year. Of the 89 MBI acquisitions interpreted as positive, there were 36 cancers. The NPV was calculated to be 99.7% (291 of 292, 95% confidence interval [CI]: 99.1%, 100%), and the FNR was 2.7% (one of 37, 95% CI: 0%, 7.9%). Interposing MBI reduced the number of biopsies by 67.5%.

Conclusion

The concept of the clinical utility of a negative MBI result may be valid but requires further testing.Keywords: Breast, Molecular Imaging-Cancer© RSNA, 2020.

Incidence and Outcome of Breast Biopsy Procedures During Follow-up After Treatment for Breast Cancer

Importance

No comprehensive data are available regarding the frequency of breast biopsies performed during follow-up of treatment for invasive breast cancer.

Objective

To determine how often patients treated for breast cancer require breast biopsies during follow-up.

Design, Setting, and Participants

This nationwide population-based cohort study included 41 510 patients 64 years or younger in a commercial insurance database and 80 369 patients 66 years or older in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Patients were diagnosed with incident invasive breast cancer (stages I-III) from January 1, 2000, through December 31, 2011. Diagnosis and procedural codes were used to identify biopsy rates during follow-up. Data were analyzed from March 3 through October 3, 2017.

Main Outcomes and Measures

Cumulative incidence and adjusted risk of breast biopsy and subsequent breast cancer treatment were calculated using the Kaplan-Meier method and Cox proportional hazards regression. All statistical tests were 2 sided.

Results

Among the 121 879 patients in the study population, 5- and 10-year overall incidences of breast biopsy were 14.7% and 23.4%, respectively, in the commercial insurance cohort and 11.8% and 14.9%, respectively, in the SEER-Medicare cohort. The 5-year estimated incidence of breast biopsy was higher among women treated with brachytherapy (24.0% in the commercial insurance and 25.0% in the SEER-Medicare cohorts) than among those treated with whole-breast irradiation (16.7% in the commercial insurance and 15.1% in the SEER-Medicare cohorts) and persisted after multivariate adjustment in the commercial insurance (hazard ratio [HR], 1.53; 95% CI, 1.38-1.70; P < .001) and SEER-Medicare (HR, 1.76; 95% CI, 1.63-1.91; P < .001) cohorts. Adjuvant chemotherapy use (HR, 1.31; 95% CI, 1.25-1.37; P < .001) and patient age (>85 vs 66-69 years; HR, 0.40; 95% CI, 0.36-0.44; P < .001) in the SEER-Medicare cohort and endocrine therapy in the commercial insurance (HR, 0.88; 95% CI, 0.82-0.93; P < .001) and SEER-Medicare (HR, 0.91; 95% CI, 0.85-0.97; P = .002) cohorts were independently associated with biopsy. After unilateral mastectomy, the estimated 5-year contralateral breast biopsy rates were 10.4% and 7.7% in the commercial insurance and SEER-Medicare cohorts, respectively. Of the patients with breast biopsy, 1239 of 4158 patients (29.8%) in the commercial insurance cohort and 2258 of 9747 patients (23.2%) in the SEER-Medicare cohort underwent subsequent cancer treatment.

Conclusions and Relevance

These data on the need for breast biopsies during follow-up and subsequent treatments from a large cohort of women with commercial insurance and Medicare can be used in the context of therapy-planning discussions and survivorship expectations for patients with breast cancer.

Using decision modeling to guide drug allocation during a shortage

BACKGROUND

Drug shortages require clinical teams to decide how to allocate drugs in limited supply among their patients. Ethical frameworks are invaluable for promoting rational approaches to drug distribution, but gaps remain between ethical theory and clinical application. The goal of this work was to explore how decision modeling could supplement ethical frameworks to inform drug distribution from the perspective of a clinical team.

PROCEDURE

We created a hypothetical pediatric oncology clinic with a limited supply of 50,000 mg of methotrexate (MTX) and 21 patients due for treatment on one of six regimens. We constructed a simple decision analytic model to compare the effectiveness of MTX in milligrams per life year saved for each regimen. The robustness of the model was tested under various conditions including alternative drug effectiveness and time horizons. Effects on outcomes and distribution by substituting alternative dosing were explored for each regimen.

RESULTS

Prescribed therapy for this group of patients required 108,791 mg MTX. Two regimens for three patients required ≥20,000 mg/m² . If distributed in order of arrival, only seven patients could receive full treatment. If distributed in order of efficiency, 19 patients could receive treatment. If less effective regimens were substituted, 20 patients could receive treatment. The primary driver of efficiency was dose per square meter.

CONCLUSIONS

In this hypothetical drug shortage, no allocation scenario exists that does not result in a worse outcome for some patients. Evidence of drug efficacy affected the decisions to substitute alternative treatments. First-come-first-served allocation resulted in fewer patients receiving treatment than allocation based on efficiency.

Multiparametric MR Imaging of Breast Cancer

Breast MR imaging has increased in popularity over the past 2 decades due to evidence of its high sensitivity for cancer detection. Current clinical MR imaging approaches rely on the use of a dynamic contrast-enhanced acquisition that facilitates morphologic and semiquantitative kinetic assessments of breast lesions. The use of more functional and quantitative parameters holds promise to broaden the utility of MR imaging and improve its specificity. Because of wide variations in approaches for measuring these parameters and the considerable technical challenges, robust multicenter data supporting their routine use are not yet available, limiting current applications of many of these tools to research purposes.

Improving early cycle economic evaluation of diagnostic technologies

The rapidly increasing range and expense of new diagnostics, compels consideration of a different, more proactive approach to health economic evaluation of diagnostic technologies. Early cycle economic evaluation is a decision analytic approach to evaluate technologies in development so as to increase the return on investment as well as patient and societal impact. This paper describes examples of 'early cycle economic evaluations' as applied to diagnostic technologies and highlights challenges in its real-time application. It shows that especially in the field of diagnostics, with rapid technological developments and a changing regulatory climate, early cycle economic evaluation can have a guiding role to improve the efficiency of the diagnostics innovation process. In the next five years the attention will move beyond the methodological and analytic challenges of early cycle economic evaluation towards the challenge of effectively applying it to improve diagnostic research and development and patient value. Future work in this area should therefore be 'strong on principles and soft on metrics', that is, the metrics that resonate most clearly with the various decision makers in this field.