Effectiveness and cost-effectiveness of sentinel lymph node biopsy compared with axillary node dissection in patients with early-stage breast cancer: a decision model analysis

Real-time detection and resection of sentinel lymph node metastasis in breast cancer through a rare earth nanoprobe based NIR-IIb fluorescence imaging

Sentinel lymph node (SLN) biopsy is a commonly employed procedure for the routine assessment of axillary involvement in patients with breast cancer. Nevertheless, conventional SLN mapping cannot reliably distinguish the presence and absence of metastatic disease. Additionally, the complex anatomical structures and lymphatic drainage patterns surrounding tumor sites pose challenges to the sensitivity of the near-infrared fluorescence imaging with subcutaneously injected probes. To identifying the SLN metastases, we developed a novel nanoprobe for in vivo fluorescence imaging within the second near-infrared (NIR-II) range. This nanoprobe utilizes rare-earth nanoparticles (RENPs) to emit bright fluorescence at 1525 nm and is conjugated with tumor-targeted hyaluronic acid (HA) to facilitate the detection of metastatic SLN. Upon intravenous administration, RENPs@HA effectively migrated to SLNs and selectively entered metastatic breast tumor cells through CD44-mediated endocytosis. The RENPs@HA nanoprobes exhibited rapid accumulation in metastatic inguinal lymph nodes in mouse model, displaying a 5.8-fold-stronger fluorescence intensity to that observed in normal SLNs. Consequently, these nanoprobes effectively differentiate metastatic SLNs from normal SLNs. Importantly, the probes accurately detected micrometastases. These findings underscore the potential of RENPs@HA for real-time visualization and screening of SLNs metastasis.

Sentinel node in breast cancer as an indicator of quality in medical care: Evaluation of statistics in Colombia

BACKGROUND

Sentinel lymph node biopsy in breast cancer is considered the standard of staging in cases of clinically negative lymph nodes. Its omission in favor of axillary dissection generates significant morbidity.

OBJECTIVE

To determine the total number of sentinel node biopsy procedures in breast cancer in Colombia from 2017 through 2020, model and analyze them as if they were performed only in stage I breast cancer patients, and integrate their results into the concepts of quality of medical care.

METHODS

Search in a database of the Ministry of Health and Social Protection of Colombia with sentinel lymph node biopsy codes, and filters of breast cancer and year. Their results are contrasted with the number of cases in stage I of breast cancer.

RESULTS

Breast cancer TNM staging was reported in 22154 cases, 3648 stage I. In the same time frame, the number of sentinel lymph node biopsies for breast cancer in Colombia was 1045, 28.64% of the total cases reported in stage I.

CONCLUSIONS

Colombia is far from complying with the standard indicator of sentinel lymph node biopsy. It is recommended to concentrate breast cancer cases in hospitals that provide the conditions for its performance.

Optical Imaging in Human Lymph Node Specimens for Detecting Breast Cancer Metastases: A Review

Assessment of regional lymph node status in breast cancer is of important staging and prognostic value. Even though formal histological examination is the currently accepted standard of care, optical imaging techniques have shown promising results in disease diagnosis. In the present article, we review six spectroscopic techniques and focus on their use as alternative tools for breast cancer lymph node assessment. Elastic scattering spectroscopy (ESS) seems to offer a simple, cost-effective, and reproducible method for intraoperative diagnosis of breast cancer lymph node metastasis. Optical coherence tomography (OCT) provides high-resolution tissue scanning, along with a short data acquisition time. However, it is relatively costly and experimentally complex. Raman spectroscopy proves to be a highly accurate method for the identification of malignant axillary lymph nodes, and it has been further validated in the setting of head and neck cancers. Still, it remains time-consuming. Near-infrared fluorescence imaging (NIRF) and diffuse reflectance spectroscopy (DFS) are related to significant advantages, such as deep tissue penetration and efficiency. Fourier-transform infrared spectroscopy (FTIR) is a promising method but has significant drawbacks. Nonetheless, only anecdotal reports exist on their clinical use for cancerous lymph node detection. Our results indicate that optical imaging methods can create informative and rapid tools to effectively guide surgical decision-making.

Cost-Effectiveness Analysis of Ultra-Hypofractionated Whole Breast Radiation Therapy Alone Versus Hormone Therapy Alone or Combined Treatment for Low-Risk ER-Positive Early Stage Breast Cancer in Women Aged 65 Years and Older

PURPOSE

The optimal management of early-stage, low-risk, hormone-positive breast cancer in older women remains controversial. Recent trials have shown that 5-fraction ultrahypofractionated whole-breast irradiation (U-WBI) has similar outcomes to longer courses, reducing the cost and inconvenience of treatment. We performed a cost-utility analysis to compare U-WBI to hormone therapy alone or their combination.

METHODS AND MATERIALS

We simulated 3 different treatment approaches for women age 65 years or older with pT1-2N0 ER-positive invasive ductal carcinoma treated with lumpectomy with negative margins using a Markov microsimulation model. The strategies were U-WBI performed with a 3-dimensional conformal technique over 5 fractions without a boost ("radiation therapy [RT] alone"), adjuvant hormone therapy (anastrozole for 5 years) without RT ("aromatase-inhibitor [AI] alone"), or the combination of the 2. The combination strategy was calibrated to match trial results, and the relative effectiveness of the RT alone and AI alone strategies were inferred from previous randomized trials. The primary endpoint was the cost-effectiveness of the 3 strategies over a lifetime horizon as measured by the incremental cost-effectiveness ratio (ICER), with a value of $100,000/quality-adjusted life-year deemed "cost-effective."

RESULTS

The model results compared with the prespecified target outcomes. On average, RT alone was the least expensive strategy ($14,775), with AI alone slightly more ($14,998), and combination therapy the costliest ($19,802). RT alone dominated AI alone (the incremental cost-effectiveness ratio [ICER] -$5089). Combination therapy, compared with RT alone, was slightly more expensive than our definition of cost-effective (ICER $113,468) but was cost-effective compared with AI alone (ICER $54,451). Probabilistic sensitivity analysis demonstrated RT alone to be cost-effective in 50% of trials, with combination therapy in 36% and AI alone in 14%.

CONCLUSIONS

U-WBI alone appears the more cost-effective de-escalation strategy for these low-risk patients, compared with AI alone. Combining U-WBI and AI appears more costly but may be preferred by some patients.

Listening to the Patient Voice Adds Value to Cancer Clinical Trials

Randomized clinical trials are critical for evaluating the safety and efficacy of interventions in oncology and informing regulatory decisions, practice guidelines, and health policy. Patient-reported outcomes (PROs) are increasingly used in randomized trials to reflect the impact of receiving cancer therapies from the patient perspective and can inform evaluations of interventions by providing evidence that cannot be obtained or deduced from clinicians' reports or from other biomedical measures. This commentary focuses on how PROs add value to clinical trials by representing the patient voice. We employed 2 previously published descriptive frameworks (addressing how PROs are used in clinical trials and how PROs have an impact, respectively) and selected 9 clinical trial publications that illustrate the value of PROs according to the framework categories. These include 3 trials where PROs were a primary trial endpoint, 3 trials where PROs as secondary endpoints supported the primary endpoint, and 3 trials where PROs as secondary endpoints contrast the primary endpoint findings in clinically important ways. The 9 examples illustrate that PROs add valuable data to the care and treatment context by informing future patients about how they may feel and function on different treatments and by providing clinicians with evidence to support changes to clinical practice and shared decision making. Beyond the patient and clinician, PROs can enable administrators to consider the cost-effectiveness of implementing new interventions and contribute vital information to policy makers, health technology assessors, and regulators. These examples provide a strong case for the wider implementation of PROs in cancer trials.

Collagen signature as a novel biomarker to predict axillary lymph node metastasis in breast cancer using multiphoton microscopy

Accurate identification of axillary lymph node (ALN) status is crucial for tumor staging procedure and decision making. This retrospective study of 898 participants from two institutions was conducted. The aim of this study is to evaluate the diagnostic performance of clinical parameters combined with collagen signatures (tumor-associated collagen signatures [TACS] and the TACS corresponding microscopic features [TCMF]) in predicting the probability of ALN metastasis in patients with breast cancer. These findings suggest that TACS and TCMF in the breast tumor microenvironment are both novel and independent biomarkers for the estimation of ALN metastasis. The nomogram based on independent clinical parameters combined with TACS and TCMF yields good diagnostic performance in predicting ALN status.

Intraoperative pathologically-calibrated diagnosis of lymph nodes involved by breast cancer cells based on electrical impedance spectroscopy; a prospective diagnostic human model study

BACKGROUND

Nodal status evaluation is a crucial step in determining prognostic factors and managing treatment strategies for breast cancer patients. Preoperative (CNB), intraoperative (SLNB), and even postoperative techniques (Formalin-Fixed Paraffin-Embedded sectioning, FFPE) have definite limitations of precision or sometimes are time-consuming for the result declaration. The primary purpose of this prospective study is to provide a precise complementary system for distinguishing lymph nodes (LNs) involved by cancerous cells in breast cancer patients intraoperatively.

METHODS

The proposed system, Electrical Lymph Scoring(ELS), is designed based on the dielectric properties of the under-test LNs. The system has a needle-shaped 2-electrode probe entered into SLNs or ALNs dissected from patients through standard surgical guidelines. Impedance magnitude in f = 1 kH (Z_1kHz) and Impedance Phase Slope in frequency ranges of 100 kHz-500 kHz (IPS) were then extracted from the impedance spectroscopy data in a cohort study of 77 breast cancer patients(totally 282 dissected LNs) who had been undergone surgery before (n = 55) or after (n = 22) chemical therapies (non-neoadjuvant or neoadjuvant chemotherapy). A new admittance parameter(Y_n^') also proposed for LN detection in neoadjuvant chemotherapy patients.

RESULTS

Considering the permanent pathology result as the gold standard checked by two independent expert pathologists, a significant correlation was observed between the presence of cancerous cells in LNs and individual ranges of the ELS electrical responses. Compared with normal LNs containing fatty ambient and immune cells, LNs involved by cancerous clusters would reduce the Z_1kHz and increase the IPS. These changes correlate with fat metabolism by cancer cells due to their Fatty Acid Oxidation (FAO) in LN, which results in different dielectric properties between high and low-fat content of normal and cancerous LNs, respectively.

CONCLUSIONS

By finding the best correlation between our defined impedimetric parameters and pathological states of tested LNs, a real-time intraoperative detection approach was developed for highly-sensitive (92%, P<0.001) diagnosis of involved sentinel or axillary LNs. The impact of real-time intraoperative scoring of SLNs would make a pre-estimation about the necessity of excising further LNs to help the surgeon for less invasive surgery, especially in the absence of frozen-section equipment.

Cost-Effectiveness Analysis of No Adjuvant Therapy Versus Partial Breast Irradiation Alone Versus Combined Treatment for Treatment of Low-Risk DCIS: A Microsimulation

PURPOSE

Adjuvant therapy in patients with ductal carcinoma in situ who undergo partial mastectomy remains controversial, particularly for low-risk patients (60 years or older, estrogen-positive, tumor extent < 2.5 cm, grade 1 or 2, and margins ≥ 3 mm). We performed a cost-effectiveness analysis comparing three strategies: no adjuvant treatment after surgery, a five-fraction course of accelerated partial breast irradiation using intensity-modulated radiation therapy (accelerated partial breast irradiation [APBI]-alone), or APBI plus an aromatase inhibitor for 5 years.

MATERIALS AND METHODS

Outcomes including local recurrence, distant metastases, and survival as well as toxicity data were modeled by a patient-level Markov microsimulation model, which were validated against trial data. Costs of treatment and possible adverse events were included from the societal perspective over a lifetime horizon, adjusted to 2019 US dollars and extracted from Medicare reimbursement data. Quality-adjusted life-years (QALYs) were calculated based on utilities extracted from the literature.

RESULTS

No adjuvant therapy was the least costly approach ($5,744), followed by APBI-alone ($11,070); combined therapy was costliest ($16,052). Adjuvant therapy resulted in slightly higher QALYs (no adjuvant, 11.320; APBI-alone, 11.343; and combination, 11.381). In the base case, no treatment was the cost-effective strategy, with an incremental cost-effectiveness ratio of $239,109/QALY for APBI-alone and $171,718/QALY for combined therapy. The incremental cost-effectiveness ratio for combined therapy compared with APBI-alone was $131,949. Probabilistic sensitivity analyses found that no therapy was cost effective (defined as $100,000/QALY of lower) in 63% of trials, APBI-alone in 19%, and the combination in 18%.

CONCLUSION

No adjuvant therapy represents the most cost-effective approach for postmenopausal women 60 years or older who receive partial mastectomy for low-risk ductal carcinoma in situ.

Clinical study of combined application of indocyanine green and methylene blue for sentinel lymph node biopsy in breast cancer

OBJECTIVE

This study aims to investigate the feasibility of combined application of indocyanine green (ICG) and methylene blue (MB) for sentinel lymph node biopsy (SLNB) in patients with early breast cancer.

METHODS

A total of 415 patients who underwent SLNB and axillary lymph node dissection were enrolled. Sentinel lymph node (SLN) was assessed in 197 patients with ICG and MB combination method, while, the other 218 patients were detected by MB method alone. During surgery, all SLNs were harvested for pathological examination. Then the detection rate and false negative rate of SLNs were comparatively analyzed between the 2 groups.

RESULTS

In the combined ICG and MB group, the detection rate of SLNs was 96.9%, significantly higher than that of MB group, which was 89.7% (P < .05). Similarly, in combined group, the average number of SLNs per patient was 3.0, much higher than that of MB group, which was 2.1 (P < .05). There was no statistically significant difference in false negative rate between combined group and MB alone group, which was 7.3% and 10.5%, respectively (P = .791).

CONCLUSION

The combined application of ICG and MB for SLNB is much more effective than MB alone in detecting SLNs.

Cost-Effectiveness Analysis from a Randomized Controlled Trial of Tailored Exercise Prescription for Women with Breast Cancer with 8-Year Follow-Up

Studies show conflicting results on whether exercise interventions to improve outcomes for women with breast cancer are cost-effective. We modelled the long-term cost-effectiveness of the Exercise for Health intervention compared with usual care. A lifetime Markov cohort model for women with early breast cancer was constructed taking a societal perspective. Data were obtained from trial, epidemiological, quality of life, and healthcare cost reports. Outcomes were calculated from 5000 Monte Carlo simulations, and one-way and probabilistic sensitivity analyses. Over the cohort's remaining life, the incremental cost for the exercise versus usual care groups were $7409 and quality-adjusted life years (QALYs) gained were 0.35 resulting in an incremental cost per QALY ratio of AU$21,247 (95% Uncertainty Interval (UI): Dominant, AU$31,398). The likelihood that the exercise intervention was cost-effective at acceptable levels was 93.0%. The incremental cost per life year gained was AU$8894 (95% UI Dominant, AU$11,769) with a 99.4% probability of being cost effective. Findings were most sensitive to the probability of recurrence in the exercise and usual care groups, followed by the costs of out-of-pocket expenses and the model starting age. This exercise intervention for women after early-stage breast cancer is cost-effective and would be a sound investment of healthcare resources.

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

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.

Cost-effectiveness analysis of endocrine therapy alone versus partial-breast irradiation alone versus combined treatment for low-risk hormone-positive early-stage breast cancer in women aged 70 years or older

PURPOSE

We performed a cost-effectiveness analysis of three strategies for the adjuvant treatment of early breast cancer in women age 70 years or older: an aromatase inhibitor (AI-alone) for 5 years, a 5-fraction course of accelerated partial-breast irradiation using intensity-modulated radiation therapy (APBI-alone), or their combination.

METHODS

We constructed a patient-level Markov microsimulation from the societal perspective. Effectiveness data (local recurrence, distant metastases, survival), and toxicity data were obtained from randomized trials when possible. Costs of side effects were included. Costs were adjusted to 2019 US dollars and extracted from Medicare reimbursement data. Quality-adjusted life-years (QALY) were calculated using utilities extracted from the literature.

RESULTS

The strategy of AI-alone ($12,637) was cheaper than both APBI-alone ($13,799) and combination therapy ($18,012) in the base case. All approaches resulted in similar QALY outcomes (AI-alone 7.775; APBI-alone 7.768; combination 7.807). In the base case, AI-alone was the cost-effective strategy and dominated APBI-alone, while combined therapy was not cost-effective when compared to AI-alone ($171,451/QALY) or APBI-alone ($107,932/QALY). In probabilistic sensitivity analyses, AI-alone was cost-effective at $100,000/QALY in 50% of trials, APBI-alone in 28% and the combination in 22%. Scenario analysis demonstrated that APBI-alone was more effective than AI-alone when AI compliance was lower than 26% at 5 years.

CONCLUSIONS

Based on a Markov microsimulation analysis, both AI-alone and APBI-alone are appropriate options for patients 70 years or older with early breast cancer with small cost differences noted. A prospective trial comparing the approaches is warranted.

Does sentinel lymph node biopsy for screening high-grade ductal carcinoma in situ of the breast cause more harm than good?

PURPOSE

Ductal carcinoma in situ (DCIS) of the breast does not metastasize to axillary lymph nodes. Yet high-grade DCIS (HgDCIS) is often subjected to Sentinel Lymph Node Biopsy (SLNB) concomitant with definitive surgery. This is to avoid further axillary surgery in the event of upstaging to invasive carcinoma, which often entails Axillary Lymph Node Dissection (ALND). We wished to examine the validity of this approach.

METHODS

This study includes a retrospective analysis of consecutive pre-operatively diagnosed HgDCIS patients from a single screening unit between December/2014 and August/2016. The main outcomes were the overall incidence of upstaging and the independent predictors of upstaging on multivariable analysis. The rates of various complications of SLNB vs ALND in four RCTs were used to calculate the upstaging rate below which SLNB could be safely omitted.

RESULTS

There were 224 eligible patients of whom 26 (11.6%) were upstaged. Axillary metastasis (pN1) occurred in two patients (0.9%). On Univariable analysis, upstaged patients were significantly younger (median (IQR) = 56.0 (51.0-63) vs 60.0 (54.0-65.0); p = 0.019). Radiological size, pathological size, type of biopsy, type of operation, and comedo-necrosis were not significant (p > 0.05). On multivariable analysis, age as a continuous variable (OR 0.93; p = 0.031) and core biopsy (OR 2.62; p = 0.036) were the only independent predictors of upstaging. Chi-square test showed that patients < 55 years whose pre-operative diagnosis was made on core biopsy were at significantly higher risk of upstaging than the others (31.8% vs 9.4%; p = 0.002).

CONCLUSION

Upstaging of HgDCIS is infrequent. According to the known rates of complications of SLNB relative to ALND, routine SLNB concomitant with surgery seems to be more harmful than its routine omission. A selective approach based on age and type of biopsy could be considered.

Individualising breast cancer treatment to improve survival and minimise complications in older women: a research programme including the PLACE RCT

Background

Over 44,000 women are diagnosed with breast cancer annually in the UK. The research comprised three workstreams (WSs) focused on older women.

Maximising survival

WS1 – to identify the role of older women’s and surgeons’ preferences in cancer treatment decisions and whether comorbidity or fitness for surgery has an impact on survival.

Minimising complications

WS2 – to assess multifrequency bioimpedance (BEA) compared with perometry in identifying women predisposed to develop lymphoedema after axillary node clearance (ANC) surgery. WS3 – to assess, in women at risk of lymphoedema, whether or not applying compression garments prevents the onset of lymphoedema.

Design

WS1 – a prospective, consecutive cohort of surgical consultations with women aged ≥ 70 years with operable breast cancer. Interviews and questionnaire surveys of surgeons’ and women’s perceptions of responsibility for treatment decisions (Controlled Preference Score), effects related to survival and secondary outcomes. WS2 – women undergoing ANC for cancer in 21 UK centres underwent baseline and subsequent BEA, and perometer arm measurements and quality-of-life (QoL) assessments. WS3 – a randomised controlled trial testing standard versus applying graduated compression garments to the affected arm, for 1 year, in WS2 patients developing arm swelling.

Setting

Breast outpatient clinics in hospitals with specialist lymphoedema clinics.

Participants

WS1 – patients aged ≥ 70 years with newly diagnosed, operable, invasive breast cancer. WS2 – women with node-positive cancer scheduled to undergo ANC. WS3 – WS2 participants developing a 4–9% increase in arm volume.

Interventions

WS1 – observational study. WS2 – observational study. WS3 – application of graduated compression garments to affected arm, compared with standard management, for 1 year.

Outcomes

WS1 – self-report and clinically assessed health, QoL, complications and survival. WS2 – perometer and bioimpedance spectroscopy (BIS) measurements, QoL and health utility; and sensitivity and specificity of BIS for detecting lymphoedema compared with perometer arm measurements; in addition, a health economics assessment was performed. WS3 – time to the development of lymphoedema [≥ 10% relative arm-volume increase (RAVI)] from randomisation.

Results

WS1 – overall, 910 women were recruited, but numbers in the substudies differ depending on consent/eligibility. In a study of patient/surgeon choice, 83.0% [95% confidence interval (CI) 80.4% to 85.6%] had surgery. Adjusting for health and choice, only women aged > 85 years had reduced odds of surgery [odds ratio (OR) 0.18, 95%CI 0.07 to 0.44]. Patient role in treatment decisions made no difference to receipt of surgery. A qualitative study of women who did not have surgery identified three groups: ‘patient declined’, ‘patient considered’ and ‘surgeon decided’. In a survival substudy, adjusting for tumour stage, comorbidity and functional status, women undergoing surgery had one-third the hazard of dying from cancer. Serious complications from surgery were low and not predicted by older age. In a substudy of the effect of surgical decision-making on HRQoL, 59 (26%) received preferred treatment decision-making style. In multivariate analyses, change in HRQoL was associated neither with congruence (p = 0.133) nor with receipt of surgery (p = 0.841). In a substudy of receipt of chemotherapy in women aged ≥ 65 years, adjusting for tumour characteristics, health measures and choice, women aged ≥ 75 years had reduced odds of chemotherapy (OR 0.06, 95%CI 0.02 to 0.16). WS2 – lymphoedema by 24 months was detected in 21.4% of women by perometry (24.4% sleeve application) and in 39.4% by BIS. Perometer and BIS measurements correlated at 6 months (r = 0.61). Specificity for sleeve application was greater for perometry (94% CI 93% to 96%) at 24 months, as was a positive predictive value of 59% (95% CI 48% to 68%). Lymphoedema diagnosis reduced QoL scores. Sleeve application in the absence of RAVI of > 9% did not improve QoL or symptoms. A composite definition of lymphoedema was developed, comprising a 9% cut-off point for perometer and self-reported considerable swelling. Diagnostic accuracy was ≥ 94% at 6, 12 and 24 months. WS3 – the PLACE (Prevention of Lymphoedema After Clearance of External compression) trial recruited 143 patients, but recruitment was slow and closed early on the advice of the Independent Data Monitoring Committee. A qualitative substudy identified a number of barriers to recruitment.

Conclusions

Half of older patients felt that they influenced decisions about their treatment. No relationship between decision preference being fulfilled and HRQoL in elderly patients diagnosed with cancer occurred, and older age did not predict complications. Primary surgery reduced the hazard of dying of cancer by two-thirds, independent of age, health and tumour characteristics. Women aged ≥ 75 years have reduced odds of receiving chemotherapy. Lymphoedema (along with a BMI of > 30 kg/m2, cigarette smoking and chemotherapy) reduces QoL. Changes in arm volume of > 9% predicted lymphoedema requiring and benefiting from sleeve application. The PLACE trial qualitative work provides a number of insights into problems of recruitment that were specific to this trial (stigma of compression garments) but that are also generalisable to other RCTs.

Limitations

Both WS1 and WS2 were large, multicentre, UK cohort, observational studies. The WS3 PLACE trial has not reported yet but closed with approximately half of the patients originally planned.

Future work

Research producing objective measures for sleeve prescription in the NHS is required.

Trial registration

Current Controlled Trials ISRCTN48880939.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 7, No. 5. See the NIHR Journals Library website for further project information. Additional support for WS1 came from a Breast Cancer Campaign Grant and a NIHR Postdoctoral Fellowship. ImpediMed (Carslbad, CA, USA;www.impedimed.com) provided bioimpedance L-Dex®machines and electrodes for the study and Sigvaris provided the external compression garments free of charge for the (PLACE) trial.

A Microsimulation Model for Evaluating the Effectiveness of Cancer Risk Management for BRCA Pathogenic Variant Carriers: miBRovaCAre

OBJECTIVES

To develop a validated model for evaluating the real-world effectiveness of long-term clinical management strategies for women with germline BRCA1 or BRCA2 pathogenic variants.

METHODS

A microsimulation model was developed that included a BRCA-specific natural history for breast and ovarian cancer, a clinical framework for carrier follow-up, and cancer risk management strategies (breast screening, risk-reducing mastectomy, and bilateral salpingo-oophorectomy). Adherence rates and outcomes for breast screening and risk-reducing surgery were obtained from BRCA carriers seen through a familial cancer service in Melbourne, Australia. The model was assessed for internal and external validity. The model was used to compare women perfectly adhering to screening recommendations versus actual adherence of the clinical cohort.

RESULTS

The model accurately predicted cancer incidence, pathology, and mortality. Using actual adherence for breast screening resulted in additional breast cancer deaths (per 1000 women: BRCA1, 2.7; BRCA2, 1.6) compared with perfect screening adherence. This decreased average life expectancy by 0.30 life-years for BRCA1 and 0.07 life-years for BRCA2. When carriers had access to risk-reducing mastectomy, the benefit from improved screening adherence was not significant.

CONCLUSIONS

The developed model is a good descriptor of BRCA carriers' lifetime trajectory and its modification by use of risk management strategies alone or in combination. Evaluations of breast screening in BRCA carriers may overestimate the benefits of screening programs unless adherence is considered. By incorporating real-world clinical practice and patient behavior, this model can assist in developing clinical services and improving clinical outcomes for carriers.

Sentinel node biopsy in patients with primary cutaneous melanoma of any thickness: A cost-effectiveness analysis

OBJECTIVE

To assess the cost-effectiveness of the sentinel node biopsy with lymphadenectomy for nodal metastases (SNB) in patients with primary cutaneous melanoma (CM) of different Breslow thickness (intermediate, thick, thin).

METHODS

Decision tree models were constructed to compare two different strategies of management of patients with CM, wide excision of the primary lesion and SNB and wide excision only (WE). Tree models were created for every Breslow thickness over 1-, 5- and 10-year time horizons. Mean and total direct healthcare costs, life years saved (LYSs), quality-adjusted life years (QALYs), cost effectiveness ratio (CER), and incremental cost effectiveness ratio (ICER) were estimated. Every model was considered as a base case, and its results tested with sensitivity analyses.

RESULTS

Base case analyses showed that the best results were obtained for intermediate CM over 10-year time horizon. In this case, ICER for SNB was 130,508€/QALY, well over the threshold of acceptance (30,000€/QALY). In patients with intermediate CM over 1 and 5 years, and for those with thick and thin CM at any time horizon, negative ICER values were estimated since SNB was proved to be more expensive and less effective than WE. Sensitivity analyses confirmed the robustness of our results.

CONCLUSIONS

SNB caused no improvement in health outcomes in terms of LYSs and QALYs in patients with thick and thin CM, and only a slight benefit in those with intermediate CM. WE was more cost-effective compared with SNB for any CM thickness over any time horizon up to 10 years.

Preoperative Sentinel Node Mapping in Sentinel Node Biopsy in Early Breast Cancers - Is It Cost-Effective?

INTRODUCTION

Sentinel lymph node (SLN) biopsy is currently the gold standard of treatment in early breast cancers. Identification of SLNs by preoperative scintigraphy has been carried out to improve the detection of SLNs intraoperatively, but the evidence of its cost-effectiveness is lacking. Here, we analyze the cost-effectiveness of the utilization of scintigraphy in detection of SLNs.

PATIENTS AND METHODS

Clinical and operative details were retrieved from a prospectively maintained database. The resources and cost data from each patient who had undergone SLN biopsy with preoperative scintigraphy were retrieved.

RESULTS

From January 2008 to December 2012, 400 patients underwent SLN biopsy for breast cancer. A total of 329 had preoperative SLN mapping with scintigraphy, Baseline patient demographic data for both arms were comparable. The relapse and recurrence rate of both arms were not statistically different. The detection rate of SLNs of both arms was the same (100%), and there were no grade 2 or above lymphedema in both groups of patients. However, the cost of each patient undergoing SLN mapping was USD $345.8.

CONCLUSION

Preoperative SLN mapping does not improve the SLN detection rate. In addition, it does not affect the surgical outcomes in terms of complication, local relapse, and recurrence. The use of preoperative SLN mapping is no longer cost-effective.

A Systematic Review of Health Economic Evaluations of Diagnostic Biomarkers

BACKGROUND

Diagnostic biomarkers have multiple applications along the care process and have a large potential in optimizing treatment decisions. However, many diagnostic biomarkers struggle to gain market access and obtain appropriate coverage because of a lack of evidence on their health economic impact.

OBJECTIVES

The aim was to review the (methodological) characteristics of recent economic evaluations on diagnostic biomarkers and examine whether these studies dealt with specific issues such as different payer perspectives, preference heterogeneity, and multiple applications in subpopulations.

METHODS

The PubMed database and the National Health Service Economic Evaluation Database were searched. Full economic evaluations published after 2009 assessing diagnostic biomarkers for the main non-communicable diseases in middle-income or high-income countries were considered eligible. Empirical and methodological study characteristics were summarized, as was the handling of specific issues related to the economic evaluation of personalized medicine.

RESULTS

Thirty-three economic evaluations were included, of which 25 were model-based analyses. The number of strategies compared ranged from two to 17 per study, and was especially large in studies assessing genetic testing in patients and their relatives. Cost-effectiveness results were most sensitive to test accuracy and costs of the biomarker (N = 7), the relative risk of an event (N = 4), and the proportion of people accepting genetic testing (N = 2). One study incorporated patient preferences, and none of the studies considered different payer perspectives, cost sharing arrangements or variable opportunity costs due to population density variability.

CONCLUSIONS

Published health economic evaluations of biomarkers used for diagnosing, staging diseases, and guiding treatment selection are characterized by a large number of comparators to model the potential clinical applications and to determine their value. Assessing outcomes beyond health as well as specific issues, such as different payer perspectives and patient preferences, is crucial to fully capture the potential health economic impact of diagnostic biomarkers and to inform value-based reimbursement.

Widespread Implications of ACOSOG Z0011: Effect on Total Mastectomy Patients

The ACOSOG Z0011 trial demonstrated that axillary lymph node dissection (ALND) is not necessary for all breast cancer patients. Patients who underwent breast conservation surgery (BCS) or total mastectomy (TM) and met Z0011 criteria were identified and sorted into pre- and post-Z0011 cohorts. Four hundred ninety four patients had breast cancer surgery from July 2008 to February 2013. Of these, 255 were pre-Z0011 and 239 were post. Pre-Z0011, 14 patients met Z0011 inclusion criteria in BCS subgroup. ALND was performed in 10 of these patients (71%). Post-Z0011, 14 patients met inclusion criteria, only 1 received ALND (7%). The decrease in ALND rate was significant (p=0.001). Pre-Z0011, 28 patients in TM subgroup met extrapolated inclusion criteria, twenty-three of which received ALND (82%). Post-Z0011, 14 patients in TM subgroup met extrapolated criteria, five of which underwent ALND (36%). The decrease in rate of ALND was significant (p=0.005). This study demonstrates that the Z0011 trial significantly altered management of the axilla in all breast cancer patients with positive sentinel lymph nodes, not just those receiving BCS.

DOES ONE SIZE FIT ALL? COST UTILITY ANALYSES OF ALTERNATIVE MAMMOGRAPHIC FOLLOW-UP SCHEDULES, BY RISK OF RECURRENCE

OBJECTIVES

International guidelines recommend annual mammography after early breast cancer, but there is no randomized controlled trial evidence to support this schedule over any other. Given that not all women have the same risk of recurrence, it is possible that, by defining different risk profiles, we could tailor mammographic schedules that are more effective and efficient.

METHODS

A discrete event simulation model was developed to describe the progression of early breast cancer after completion of primary treatment. Retrospective data for 1,100 postmenopausal women diagnosed with early breast cancer in South Australia from 2000 to 2008 were used to calibrate the model. Women were divided into four prognostic subgroups based on the Nottingham Prognostic Index of their primary tumor. For each subgroup, we compared the cost-effectiveness of three different mammographic schedules for two different age groups.

RESULTS

Annual mammographic follow-up was not cost-effective for most postmenopausal women. Two yearly mammography was cost-effective for all women with excellent prognosis tumors; and for women with good prognosis tumors if high compliance rates can be achieved. Annual mammography for 5 years and 2 yearly surveillance thereafter (a mixed schedule) may be cost-effective for 50- to 69-year-old women with moderate prognosis tumors, and for women aged 70-79 years with poor prognosis tumors. For younger women with poor prognosis tumors, annual mammography is potentially cost-effective.

CONCLUSIONS

Our results suggest that mammographic follow-up could be tailored according to risk of recurrence. If validated with larger datasets, this could potentially set the stage for personalized mammographic follow-up after breast cancer.

A patient-level calibration framework for evaluating surveillance strategies: a case study of mammographic follow-up after early breast cancer

OBJECTIVE

Currently all women who have completed their primary treatment for early breast cancer are invited to receive routine annual mammography. There is no randomized controlled trial evidence to support this schedule, and model-based analysis is required. This paper describes a novel data collection and model calibration process to analyze the cost-effectiveness of alternative follow-up schedules for early breast cancer survivors.

METHODS

A discrete event simulation model describes the progression of early breast cancer after the completion of primary treatment, representing impalpable and palpable recurrence and the detection of impalpable disease via follow-up mammography. Retrospective data from the South Australian Cancer Registry and clinical and administrative hospital databases were linked for 407 postmenopausal women diagnosed with moderate-prognosis early breast cancer from 2000 to 2008. These data formed the basis of a patient-level probabilistic calibration process.

RESULTS

For 50- to 69-year-old survivors, annual follow-up for 5 years, with visits every 2 years thereafter, appears to be cost-effective. For women aged 70 to 79 years at diagnosis, a surveillance schedule similar to general population screening (2 yearly) appears to be most cost-effective if high rates of adherence can be maintained.

CONCLUSIONS

This study demonstrated the potential value of combining linked, retrospective data and decision analytic modeling to provide estimates of costs and health outcomes that are sufficiently robust to inform cancer clinical guidelines and individual patient decisions regarding appropriate follow-up schedules.

A Cost-Utility Analysis Comparing Standard Axillary Lymph Node Dissection with Sentinel Lymph Node Biopsy in Patients with Early Stage Breast Cancer in Thailand

OBJECTIVES

In Thailand, axillary lymph node dissection (ALND) is the dominant form of treatment for breast cancer, even though the treatment often leaves patients with some degree of arm morbidity. Sentinel lymph node biopsy (SNB) is widely accepted globally as a preferable alternative procedure because of its lower rates of associated morbidity. This study compared the cost-utility of SNB and ALND in patients with early stage breast cancer in Thailand.

METHODS

A decision tree with a 5-year time horizon was developed. Outcomes that were relevant to SNB and ALND were included, along with locoregional recurrence of cancer and lymphedema scenarios. The model parameters were derived from a meta-analysis of international clinical trials and other relevant literature. The resources and cost data were derived from the medical records of tertiary hospitals. Health utilities were measured by using the standard gamble technique. A sensitivity analysis was performed using a set of plausible parameters.

RESULTS

The incremental cost-effectiveness ratio (ICER) in the base-case analysis showed that SNB was more cost-effective than ALND. ICERs were -275,140 and -470,600 Thailand baht/quality-adjusted life-year gained from the provider perspective and the societal perspective, respectively. The most sensitive parameter was the utility score of patients with early stage breast cancer who had received breast-conserving therapy with lymphedema; the sensitivity and specificity of SNB had no impact on the ICER.

CONCLUSIONS

The study confirmed that SNB was an economically viable alternative treatment to ALND. In developing countries, where resources are limited, nationwide implementation of SNB warrants widespread support from relevant stakeholders, including medical personnel and policymakers.

Selective axillary dissection after axillary reverse mapping to prevent breast-cancer-related lymphoedema

BACKGROUND

It has recently been reported that, using axillary reverse mapping (ARM), the lymphatics from the arm can be spared to reduce the incidence of breast-cancer-related lymphoedema (BCRL). The aim of this study was to assess the feasibility of selective axillary dissection (SAD) after using ARM and partially preserving arm drainage, and to assess the occurrence of BCRL.

METHODS

Using a radioisotope and lymphoscintigraphy, ARM was performed in 60 patients scheduled for SAD, who were subsequently divided for the purpose of comparing the BCRL rates into: group A, comprising 45 patients who successfully underwent SAD with a residual lymphatic hot spot; and group B with 15 whose hot nodes were removed as is normally the case during complete axillary lymph node dissection (ALND).

RESULTS

SAD was feasible in 75% of the 60 patients. SAD was completed successfully in 19 of the first 30 patients, and in 26 of the second 30 patients (p = 0.072). The median follow-up was 16 months (6-36), during which 9 patients developed a BCRL, 4 in group A (9%) and 5 in group B (33%); p = 0.035. None of the patients had nodal relapses during the follow-up.

CONCLUSIONS

Using a radioisotope enables an effective and safe SAD in a large proportion of patients. There was evidence of a trend to suggest a learning curve. The rate of BCRL after SAD was less than one third of the rate recorded after ALND, a result that should encourage the development of the former technique.

Application of ACOSOG Z0011 criteria reduces perioperative costs

BACKGROUND

The ACOSOG Z0011 (Z0011) trial concluded that sentinel lymph node biopsy (SLNB) without completion axillary lymph node dissection (ALND) provides excellent regional control in women with T1-T2 sentinel lymph node (SLN) positive breast cancers receiving breast conservation therapy. We determined whether application of Z0011 guidelines would reduce costs.

METHODS

A retrospective chart review of patients with invasive breast cancer treated with lumpectomy and SLNB at our institution during 2009 was performed. We determined the number of overnight hospital admissions following ALND and estimated costs pertaining to the perioperative surgical management of the axilla patients actually received, and compared those to the estimated number of inpatient days and perioperative costs if Z0011 guidelines had been followed for eligible patients. The 2011 Medicare Fee Schedule was used to estimate costs for procedures, and costs for OR time were estimated using procedure length and cost of OR time per minute.

RESULTS

A total of 71 patients underwent lumpectomy with SLNB and had at least 1 positive SLN. Estimated costs related to perioperative surgical management of the axilla were $322,775, and there were 36 overnight admissions. Applying Z0011 criteria, 51 patients (72%) would have been eligible to forego completion ALND. Estimated costs would have been $264,513 with 13 overnight admissions, translating into a cost savings of $58,262 and 23 fewer overnight admissions.

CONCLUSION

Application of Z0011 guidelines resulted in cost savings, with a 64% reduction in inpatient hospital days and an 18% reduction in early perioperative costs.