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Chaballout BH, Chang EM, Parikh NR, Min Y, Raldow AC. Assessing utilities for muscle-invasive bladder cancer-related health states. Urol Oncol 2023; 41:456.e7-456.e12. [PMID: 37524576 DOI: 10.1016/j.urolonc.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/12/2023] [Accepted: 07/10/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVES How patients value functional outcomes against oncologic outcomes during decision-making for muscular-invasive bladder cancer (MIBC) remains unclear. We sought to quantify individuals' preferences on a scale of 0 to 1, where 1 represents perfect health and 0 represents death. METHODS Descriptions of 6 hypothetical health states were developed. These included: Neoadjuvant chemotherapy followed by radical cystectomy with ileal conduit (IC) or with neobladder reconstruction (NB), Transurethral resection and chemotherapy/radiation (CRT), CRT requiring salvage cystectomy (SC), Recurrent/metastatic bladder cancer after local therapy (RMBC), and Metastatic bladder cancer (MBC). Descriptions consisted of diagnosis, treatments, adverse effects, follow-up protocol, and prognosis and were reviewed for accuracy by expert panel. Included individuals were asked to evaluate states using the visual analog scale (VAS) and standard gamble (SG) methods. RESULTS Fifty-four individuals were included for analysis. No score differences were observed between IC, NB, and CRT on VAS or SG. On VAS, SC (value = 0.429) was rated as significantly worse (P < 0.001) than NB (value = 0.582) and CRT (value = 0.565). However, this was not the case using the SG method. Both RMBC (VAS value = 0.178, SG value = 0.631) and MBC (VAS value = 0.169, SG value = 0.327) rated as significantly worse (P < 0.001) than the other states using both VAS and SG. CONCLUSIONS Within this sample of the general population, preferences for local treatments including IC, NB, and CRT were not found to be significantly different. These values can be used to calculate quality-adjusted life expectancy in future cost-effectiveness analyses.
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Affiliation(s)
- Basil H Chaballout
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, SC
| | - Eric M Chang
- Interstate Radiation Oncology Center, Kaiser Permanente Northwest, Portland, Oregon
| | - Neil R Parikh
- Department of Radiation Oncology, UCLA, Los Angeles, CA
| | - Yugang Min
- Department of Radiation Oncology, UCLA, Los Angeles, CA
| | - Ann C Raldow
- Department of Radiation Oncology, UCLA, Los Angeles, CA.
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2
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Haussmann J, Budach W, Corradini S, Krug D, Bölke E, Tamaskovics B, Jazmati D, Haussmann A, Matuschek C. Whole Breast Irradiation in Comparison to Endocrine Therapy in Early Stage Breast Cancer-A Direct and Network Meta-Analysis of Published Randomized Trials. Cancers (Basel) 2023; 15:4343. [PMID: 37686620 PMCID: PMC10487067 DOI: 10.3390/cancers15174343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Multiple randomized trials have established adjuvant endocrine therapy (ET) and whole breast irradiation (WBI) as the standard approach after breast-conserving surgery (BCS) in early-stage breast cancer. The omission of WBI has been studied in multiple trials and resulted in reduced local control with maintained survival rates and has therefore been adapted as a treatment option in selected patients in several guidelines. Omitting ET instead of WBI might also be a valuable option as both treatments have distinctly different side effect profiles. However, the clinical outcomes of BCS + ET vs. BCS + WBI have not been formally analyzed. METHODS We performed a systematic literature review searching for randomized trials comparing BCS + ET vs. BCS + WBI in low-risk breast cancer patients with publication dates after 2000. We excluded trials using any form of chemotherapy, regional nodal radiation and mastectomy. The meta-analysis was performed using a two-step process. First, we extracted all available published event rates and the effect sizes for overall and breast-cancer-specific survival (OS, BCSS), local (LR) and regional recurrence, disease-free survival, distant metastases-free interval, contralateral breast cancer, second cancer other than breast cancer and mastectomy-free interval as investigated endpoints and compared them in a network meta-analysis. Second, the published individual patient data from the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) publications were used to allow a comparison of OS and BCSS. RESULTS We identified three studies, including a direct comparison of BCS + ET vs. BCS + WBI (n = 1059) and nine studies randomizing overall 7207 patients additionally to BCS only and BCS + WBI + ET resulting in a four-arm comparison. In the network analysis, LR was significantly lower in the BCS + WBI group in comparison with the BCS + ET group (HR = 0.62; CI-95%: 0.42-0.92; p = 0.019). We did not find any differences in OS (HR = 0.93; CI-95%: 0.53-1.62; p = 0.785) and BCSS (OR = 1.04; CI-95%: 0.45-2.41; p = 0.928). Further, we found a lower distant metastasis-free interval, a higher rate of contralateral breast cancer and a reduced mastectomy-free interval in the BCS + WBI-arm. Using the EBCTCG data, OS and BCSS were not significantly different between BCS + ET and BCS + WBI after 10 years (OS: OR = 0.85; CI-95%: 0.59-1.22; p = 0.369) (BCSS: OR = 0.72; CI-95%: 0.38-1.36; p = 0.305). CONCLUSION Evidence from direct and indirect comparison suggests that BCS + WBI might be an equivalent de-escalation strategy to BCS + ET in low-risk breast cancer. Adverse events and quality of life measures have to be further compared between these approaches.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University (LMU), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Alexander Haussmann
- Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
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Kim H, Wang H, Demanelis K, Clump DA, Vargo JA, Keller A, Diego M, Gorantla V, Smith KJ, Rosenzweig MQ. Factors associated with ductal carcinoma in situ (DCIS) treatment patterns and patient-reported outcomes across a large integrated health network. Breast Cancer Res Treat 2023; 197:683-692. [PMID: 36526807 PMCID: PMC9883362 DOI: 10.1007/s10549-022-06831-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE To examine associations between ductal carcinoma in situ (DCIS) patients' characteristics, treating locations and DCIS treatments received and to pilot assessing quality-of-life (QoL) values among DCIS patients with diverse backgrounds. METHODS We performed a retrospective tumor registry review of all patients diagnosed and treated with DCIS from 2018 to 2019 in the UPMC-integrated network throughout central and western Pennsylvania. Demographics, clinical information, and administered treatments were compiled from tumor registry records. We categorized contextual factors such as different hospital setting (academic vs. community), socioeconomic status based on the neighborhood deprivation index (NDI) as well as age and race. QoL survey was administered to DCIS patients with diverse backgrounds via QoL questionnaire breast cancer module 23 and qualitative assessment questions. RESULTS A total of 912 patients were reviewed. There were no treatment differences noted for age, race, or NDI. Mastectomy rate was higher in academic sites than community sites (29 vs. 20.4%; p = 0.0045), while hormone therapy (HT) utilization rate was higher in community sites (74 vs. 62%; p = 0.0012). QoL survey response rate was 32%. Only HT side effects negatively affected in QoL scores and there was no significant difference in QoL domains and decision-making process between races, age, NDI, treatment groups, and treatment locations. CONCLUSION Our integrated health network did not show chronically noted disparities arising from social determinates of health for DCIS treatments by implementing clinical pathways and system-wide peer review. Also, we demonstrated feasibility in collecting QoL for DCIS women with diverse backgrounds and different socioeconomic statuses.
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Affiliation(s)
- Hayeon Kim
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA.
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Magee Women's Hospital, 300 Halket Street, Pittsburgh, PA, 15213, USA.
| | - Hong Wang
- Department of Biostatistics, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Kathryn Demanelis
- Department of Biostatistics, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - David A Clump
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - John A Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Andrew Keller
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Mia Diego
- Department of Breast Surgery, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Vikram Gorantla
- Department of Medical Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Clinical and Translational Science and Center for Research On Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Margaret Q Rosenzweig
- Department of Nursing, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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4
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Rodin D, Sutradhar R, Nofech-Mozes S, Gu S, Faught N, Hahn E, Fong C, Trebinjac S, Paszat L, Rakovitch E. Long-term outcomes of women with large DCIS lesions treated with breast-conserving therapy. Breast Cancer Res Treat 2022; 192:223-233. [PMID: 35083587 DOI: 10.1007/s10549-021-06488-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The paucity of data on women with large (≥ 40 mm) DCIS tumors lead to uncertainty on the safety of breast-conserving surgery (BCS) for these patients. We evaluated the impact of large tumor size on local recurrence (LR) among women with DCIS treated with BCS ± radiotherapy (RT). METHODS Treatment and outcomes were ascertained through administrative databases for all women with DCIS in Ontario from 1994 to 2003 treated with BCS ± RT with negative margins; 82% had pathology review. Cox proportional hazards model was used to evaluate the impact of tumor size on LR. 10- and 15-year LR-free survival (LRFS) were calculated using Kaplan-Meier method. RESULTS The cohort includes 2049 women treated by BCS (N = 1073 with RT). Median follow-up is 14 years (IQR 9-17 years). Referenced to tumors ≤ 10 mm, the risk of LR following BCS was significantly higher for larger tumors: HR ≥ 40 mm = 3.67 (95% CI 2.13, 6.33; p < 0.001), HR 26-39 mm = 2.27 (95% CI 1.47, 3.50, p < 0.001), and HR 11-25 mm = 1.42 (95% CI 1.06, 1.92, p = 0.02). However, for individuals with BCS + RT, large tumor size was not associated with a significantly increased risk of LR (HR ≥ 40 mm = 1.92 (95% CI 0.97, 3.79); HR 26-39 mm = 1.81 (95% CI 1.09-2.99)). For women with tumors ≥ 40 mm, 10-year LRFS risk for those treated by BCS alone, BCS + RT without boost, and BCS + RT with boost was 58.9%, 82.8%, and 83.9%. CONCLUSION Large DCIS lesions ≥ 40 mm are associated with higher risks of LR following BCS, but high long-term LRFS rates can be achieved with the addition of breast RT.
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Affiliation(s)
- Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, 700 University Avenue, Room 7-611, Toronto, ON, M4R 1M3, Canada. .,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Sharon Nofech-Mozes
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Pathology, University of Toronto, Toronto, ON, Canada
| | - Sumei Gu
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Neil Faught
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Ezra Hahn
- Radiation Medicine Program, Princess Margaret Cancer Centre, 700 University Avenue, Room 7-611, Toronto, ON, M4R 1M3, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Cindy Fong
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Sabina Trebinjac
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lawrence Paszat
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Eileen Rakovitch
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Kaur MN, Yan J, Klassen AF, David JP, Pieris D, Sharma M, Bordeleau L, Xie F. A Systematic Literature Review of Health Utility Values in Breast Cancer. Med Decis Making 2022; 42:704-719. [PMID: 35042379 PMCID: PMC9189726 DOI: 10.1177/0272989x211065471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Health utility values (HUVs) are important inputs to the cost-utility analysis of breast cancer interventions. PURPOSE Provide a catalog of breast cancer-related published HUVs across different stages of breast cancer and treatment interventions. DATA SOURCES Systematic searches of MEDLINE, MEDLINE In-Process, EMBASE, Web of Science, CINAHL, PsycINFO, EconLit, and Cochrane databases (2005-2017). STUDY SELECTION Studies published in English that reported mean or median HUVs using direct or indirect methods of utility elicitation for breast cancer. DATA EXTRACTION Independent reviewers extracted data on a preestablished and piloted form; disagreements were resolved through discussion. DATA ANALYSIS Mixed-effects meta-regression using restricted maximum likelihood modeling was conducted for intervention type, stage of breast cancer, and typical clinical and treatment trajectory of breast cancer patients to assess the effect of study characteristics (i.e., sample size, utility elicitation method, and respondent type) on HUVs. DATA SYNTHESIS Seventy-nine studies were included in the review. Most articles (n = 52, 66%) derived HUVs using the EQ-5D. Patients with advanced-stage breast cancer (range, 0.08 to 0.82) reported lower HUVs as compared with patients with early-stage breast cancer (range, 0.58 to 0.99). The meta-regression analysis found that undergoing chemotherapy and surgery and radiation, being diagnosed with an advanced stage of breast cancer, and recurrent cancer were associated with lower HUVs. The members of the general public reported lower HUVs as compared with patients. LIMITATIONS There was considerable heterogeneity in the study population, health states assessed, and utility elicitation methods. CONCLUSION This review provides a catalog of published HUVs related to breast cancer. The substantial heterogeneity in the health utility studies makes it challenging for researchers to choose which HUVs to use in cost-utility analyses for breast cancer interventions.
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Affiliation(s)
- Manraj N Kaur
- School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Jiajun Yan
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Anne F Klassen
- Department of Pediatrics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Justin P David
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dilshan Pieris
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Manraj Sharma
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Louise Bordeleau
- Department of Oncology, Division of Medical Oncology, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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Gupta A, Jhawar SR, Sayan M, Yehia ZA, Haffty BG, Yu JB, Wang SY. Cost-Effectiveness of Adjuvant Treatment for Ductal Carcinoma In Situ. J Clin Oncol 2021; 39:2386-2396. [PMID: 34019456 PMCID: PMC10166354 DOI: 10.1200/jco.21.00831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Ductal carcinoma in situ (DCIS) accounts for 20% of breast cancer cases in the United States and is potentially overtreated, leading to high expenditures and low-value care. We conducted a cost-effectiveness analysis evaluating all adjuvant treatment strategies for DCIS. METHODS A Markov model was created with six competing treatment strategies: observation, tamoxifen (TAM) alone, aromatase inhibitor (AI) alone, radiation treatment (RT) alone, RT + TAM, and RT + AI. Baseline recurrence rates were modeled using the NSABP B17 and RTOG 9804 trials for standard-risk and good-risk DCIS, respectively. Relative risk reductions and adverse event rates for each treatment strategy were derived from meta-analyses of large randomized trials. We used a willingness-to-pay threshold of $100,000 in US dollars/quality-adjusted life-year and a lifetime horizon for two cohorts of women, age 40 and 60 years. Comprehensive sensitivity analyses evaluated the robustness of base-case results. RESULTS RT alone was cost-effective for patients with standard-risk DCIS, and observation was cost-effective for patients with good-risk DCIS, across both age groups. Strategies including TAM or AI resulted in fewer quality-adjusted life-years than observation, because of the prolonged decrement in quality of life outweighing the modest benefit in ipsilateral risk reduction. In sensitivity analysis, RT alone was cost-effective for age 40, good-risk patients when ipsilateral risk reduction matched that of the RTOG 9804 trial, there was minimal increased risk of contralateral breast secondary malignancy, or there was strong patient willingness to pursue RT. CONCLUSION Our findings suggest that cost-effective and clinically optimal treatment strategies are RT alone for standard-risk DCIS and observation for good-risk DCIS, with personalization on the basis of patient age and preference for RT. Hormonal therapy is likely suboptimal for most patients with DCIS.
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Affiliation(s)
- Apar Gupta
- Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Sachin R Jhawar
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Mutlay Sayan
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Zeinab A Yehia
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Bruce G Haffty
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - James B Yu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - Shi-Yi Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Yale School of Public Health, New Haven, CT
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Cost-Effectiveness Analysis of Biological Signature DCISionRT Use for DCIS Treatment. Clin Breast Cancer 2020; 21:e271-e278. [PMID: 33218957 DOI: 10.1016/j.clbc.2020.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/28/2020] [Accepted: 10/20/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Currently it remains difficult to identify patients most likely to benefit from radiotherapy (RT) for ductal carcinoma-in-situ (DCIS), thus leading to wide variation in practice patterns. The genomic risk assessment tool DCISionRT (PreludeDX) has been validated to prognosticate recurrence risk and predict RT benefit. We aimed to study the cost-effectiveness analysis comparing DCIS treatments based on DCISionRT testing to traditional clinicopathologic risk factors. PATIENTS AND METHODS A Markov state transition model was constructed to perform a cost-effectiveness analysis comparing breast-conserving surgery with or without RT using DCISionRT testing vs. traditional clinicopathologic risk factors. Clinical parameters were obtained from clinical trial data and cross-validation studies. Cost data were based on 2019 Medicare reimbursement. Incremental cost-effectiveness ratio (ICER) was calculated as incremental cost per quality-adjusted life-year (QALY) gained comparing DCIS treatments using DCISionRT testing to traditional clinicopathologic risk factors and evaluated with a willingness-to-pay threshold of US$100,000 per QALY gained. To account for uncertainty, 1-way and probabilistic sensitivity analyses were performed. RESULTS Base case analysis showed that DCIS management using DCISionRT testing was a cost-effective strategy, resulting in an ICER of $74,331 per QALY gained compared to clinicopathology-based treatment. Model results were sensitive to a variation of the proportion of genomic-high, low-risk patients receiving RT in DCISionRT testing strategy, and changes in DCISionRT testing cost. CONCLUSION DCISionRT testing could potentially be a cost-effective strategy compared to traditional decision making for DCIS treatments, optimizing RT benefit based on an accurate recurrence risk assessment.
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Raldow AC, Sher D, Chen AB, Punglia RS. Cost Effectiveness of DCISionRT for Guiding Treatment of Ductal Carcinoma in Situ. JNCI Cancer Spectr 2020; 4:pkaa004. [PMID: 32211582 PMCID: PMC7083239 DOI: 10.1093/jncics/pkaa004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/30/2019] [Accepted: 01/22/2020] [Indexed: 11/14/2022] Open
Abstract
The DCISionRT test estimates the risk of an ipsilateral breast event (IBE) in patients with ductal carcinoma in situ (DCIS) as well as the benefit of adjuvant radiation therapy (RT). We determined the cost-effectiveness of DCISionRT using a Markov model simulating 10-year outcomes for 60-year-old women with DCIS based on nonrandomized data. Three strategies were compared: no testing, no RT (strategy 1); test all, RT for elevated risk only (strategy 2); and no testing, RT for all (strategy 3). We used utilities and costs from the literature and Medicare claims to determine incremental cost-effectiveness ratios and examined the number of women irradiated per IBE prevented. In the base-case scenario, strategy 1 was the cost-effective strategy. Strategy 2 was cost-effective compared with strategy 3 when the cost of DCISionRT was less than $4588. The number irradiated per IBE prevented were 8.37 and 15.46 for strategies 2 and 3, respectively, relative to strategy 1.
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Affiliation(s)
- Ann C Raldow
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Correspondence to: Ann C. Raldow, MD, MPH, Department of Radiation Oncology, University of California Los Angeles, 200 Medical Plaza Driveway, Suite #B265, Los Angeles, CA 90095-6951 (e-mail: )
| | - David Sher
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA
| | - Aileen B Chen
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Rinaa S Punglia
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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9
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Bromley HL, Mann GB, Petrie D, Nickson C, Rea D, Roberts TE. Valuing preferences for treating screen detected ductal carcinoma in situ. Eur J Cancer 2019; 123:130-137. [PMID: 31689678 DOI: 10.1016/j.ejca.2019.09.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Mammographic screening reduces breast cancer mortality but may lead to the overdiagnosis and overtreatment of low-risk breast cancers. Conservative management may reduce the potential harm of overtreatment, yet little is known about the impact upon quality of life. OBJECTIVES To quantify women's preferences for managing low-risk screen detected ductal carcinoma in situ (DCIS), including the acceptability of active monitoring as an alternative treatment. METHODS Utilities (cardinal measures of quality of life) were elicited from 172 women using visual analogue scales (VASs), standard gambles, and the Euro-Qol-5D-5L questionnaire for seven health states describing treatments for low-risk DCIS. Sociodemographics and breast cancer history were examined as predictors of utility. RESULTS Both patients and non-patients valued active monitoring more favourably on average than conventional treatment. Utilities were lowest for DCIS treated with mastectomy (VAS: 0.454) or breast conserving surgery (BCS) with adjuvant radiotherapy (VAS: 0.575). The utility of active monitoring was comparable to BCS alone but was rated more favourably as progression risk was reduced from 40% to 10%. Disutility for active monitoring was likely driven by anxiety around progression, whereas conventional management impacted other dimensions of quality of life. The heterogeneity between individual preferences could not be explained by sociodemographic variables, suggesting that the factors influencing women's preferences are complex. CONCLUSIONS Active monitoring of low-risk DCIS is likely to be an acceptable alternative for reducing the impact of overdiagnosis and overtreatment in terms of quality of life. Further research is required to determine subgroups more likely to opt for conservative management.
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Affiliation(s)
- Hannah L Bromley
- Health Economics Unit, University of Birmingham, Edgbaston, West Midlands, UK; Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia
| | - G Bruce Mann
- Department of Surgery, University of Melbourne, Parkville, Australia
| | - Dennis Petrie
- Centre for Health Economics, Monash Business School, Monash University, Australia
| | - Carolyn Nickson
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia; Cancer Research Division, Cancer Council NSW, Australia
| | - Daniel Rea
- Cancer Research UK Clinical Trials Unit, University Hospital of Birmingham, West Midlands, UK
| | - Tracy E Roberts
- Health Economics Unit, University of Birmingham, Edgbaston, West Midlands, UK.
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10
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Srikanthan A, Amir E, Gupta A, Baxter N, Kennedy ED. Assisting with Decision-Making: How Standardized Information Impacts Breast Cancer Patient Decisions Regarding Fertility Trade-Offs and Chemotherapy. J Adolesc Young Adult Oncol 2019; 8:660-667. [PMID: 31241397 DOI: 10.1089/jayao.2019.0027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Fertility is a concern for young women with breast cancer. We explore patient preferences for chemotherapy and whether women will trade-off survival benefits to maintain fertility following standardized information delivery. Methods: During a standardized interview, outcomes associated with adjuvant chemotherapy and 5 years of tamoxifen (CT) or 5 years of tamoxifen alone (NoCT) were described to participants. A threshold task was performed, in which each participant participated in two scenarios: (1) 10% absolute survival benefit from treatment and (2) 25% absolute survival benefit from treatment. The threshold point represented the reduction in fertility post-treatment that a participant would accept before she would trade-off CT benefit. Descriptive statistics were used to characterize participants. Demographic factors (age, marital status, parity at diagnosis, and education) associated with willingness to trade-off survival benefits were evaluated with logistic regression. Results: Analysis comprised 50 women with a median age of 34.5 years (range 25-39 years). Thirty-nine women (78%) completed university education. Thirty-four (68%) and 45 (90%) women in scenarios 1 and 2, respectively, were willing to trade-off all fertility (i.e., reduce fertility to 0% chance of conceiving naturally) to undertake CT and maintain survival benefits. Eight (16%) and three (6%) women in scenarios 1 and 2, respectively, chose to not pursue CT at all to maintain natural fertility. Regression analysis did not identify any variables that were predictive of participants' preferences. Conclusion: Most women with breast cancer are not willing to trade-off survival benefits of adjuvant therapy to maintain fertility.
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Affiliation(s)
- Amirrtha Srikanthan
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Eitan Amir
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Abha Gupta
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nancy Baxter
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Keenan Research Centre of the Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Erin Diane Kennedy
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.,Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
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11
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Bromley HL, Petrie D, Mann GB, Nickson C, Rea D, Roberts TE. Valuing the health states associated with breast cancer screening programmes: A systematic review of economic measures. Soc Sci Med 2019; 228:142-154. [PMID: 30913528 DOI: 10.1016/j.socscimed.2019.03.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/21/2019] [Accepted: 03/15/2019] [Indexed: 12/26/2022]
Abstract
Policy decisions regarding breast cancer screening and treatment programmes may be misplaced unless the decision process includes the appropriate utilities and disutilities of mammography screening and its sequelae. The objectives of this study were to critically review how economic evaluations have valued the health states associated with breast cancer screening, and appraise the primary evidence informing health state utility values (cardinal measures of quality of life). A systematic review was conducted up to September 2018 of studies that elicited or used utilities relevant to mammography screening. The methods used to elicit utilities and the quality of the reported values were tabulated and analysed narratively. 40 economic evaluations of breast cancer screening programmes and 10 primary studies measuring utilities for health states associated with mammography were reviewed in full. The economic evaluations made different assumptions about the measures used, duration applied and the sequalae included in each health state. 22 evaluations referenced utilities based on assumptions or used measures that were not methodologically appropriate. There was significant heterogeneity in the utilities generated by the 10 primary studies, including the methods and population used to derive them. No study asked women to explicitly consider the risk of overdiagnosis when valuing the health states described. Utilities informing breast screening policy are restricted in their ability to reflect the full benefits and harms. Evaluating the true cost-effectiveness of breast cancer screening will remain problematic, unless the methodological challenges associated with valuing the disutilities of screening are adequately addressed.
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Affiliation(s)
- Hannah L Bromley
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia; Health Economics Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Dennis Petrie
- Centre for Health Economics, Monash University, Melbourne, Victoria, Australia
| | - G Bruce Mann
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Carolyn Nickson
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia; Cancer Research Division, Cancer Council NSW, Australia
| | - Daniel Rea
- Cancer Research UK Clinical Trials Unit, University Hospital of Birmingham, Birmingham, West Midlands, UK
| | - Tracy E Roberts
- Health Economics Unit, University of Birmingham, Birmingham, West Midlands, UK.
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12
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Torres MA. Genomic Assays to Assess Local Recurrence Risk and Predict Radiation Therapy Benefit in Patients With Ductal Carcinoma In Situ. Int J Radiat Oncol Biol Phys 2019; 103:1021-1025. [PMID: 30900551 DOI: 10.1016/j.ijrobp.2018.10.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 10/17/2018] [Accepted: 10/19/2018] [Indexed: 11/28/2022]
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13
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Punglia RS, Bifolck K, Golshan M, Lehman C, Collins L, Polyak K, Mittendorf E, Garber J, Hwang SE, Schnitt SJ, Partridge AH, King TA. Epidemiology, Biology, Treatment, and Prevention of Ductal Carcinoma In Situ (DCIS). JNCI Cancer Spectr 2018; 2:pky063. [PMID: 30627695 PMCID: PMC6307658 DOI: 10.1093/jncics/pky063] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/12/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) is a highly heterogeneous disease. It presents in a variety of ways and may or may not progress to invasive cancer, which poses challenges for both diagnosis and treatment. On May 15, 2017, the Dana-Farber/Harvard Cancer Center hosted a retreat for over 80 breast specialists including medical oncologists, surgical oncologists, radiation oncologists, radiologists, pathologists, physician assistants, nurses, nurse practitioners, researchers, and patient advocates to discuss the state of the science, treatment challenges, and key questions relating to DCIS. Speakers and attendees were encouraged to explore opportunities for future collaboration and research to improve our understanding and clinical management of this disease. Participants were from Dana-Farber Cancer Institute, Brigham and Women's Hospital, Massachusetts General Hospital, Beth Israel Deaconess Medical Center, Duke University Medical Center, and MD Anderson Cancer Center. The discussion focused on three main themes: epidemiology, detection, and pathology; state of the science including the biology of DCIS and potential novel treatment approaches; and risk perceptions, communication, and decision-making. Here we summarize the proceedings from this event.
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Affiliation(s)
| | | | - Mehra Golshan
- Surgical Oncology, Division of Breast Surgery, Department of Surgery
| | - Constance Lehman
- Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Laura Collins
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Elizabeth Mittendorf
- Surgical Oncology, Division of Breast Surgery, Department of Surgery
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Shelley E Hwang
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Stuart J Schnitt
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
- Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA
| | | | - Tari A King
- Surgical Oncology, Division of Breast Surgery, Department of Surgery
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14
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Omitting radiation therapy after lumpectomy for pure DCIS does not reduce the risk of salvage mastectomy. Breast 2018; 37:181-186. [DOI: 10.1016/j.breast.2017.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 06/26/2017] [Accepted: 07/05/2017] [Indexed: 11/20/2022] Open
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15
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Schiller-Frühwirth IC, Jahn B, Arvandi M, Siebert U. Cost-Effectiveness Models in Breast Cancer Screening in the General Population: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:333-351. [PMID: 28185134 DOI: 10.1007/s40258-017-0312-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Many Western countries have long-established population-based mammography screening programs. Prior to implementing these programs, decision-analytic modeling was widely used to inform decisions. OBJECTIVE The aim of this study was to perform a systematic review of cost-effectiveness models in breast cancer screening in the general population to analyze their structural and methodological approaches. METHODS A systematic literature search for health economic models was performed in the electronic databases MEDLINE (Ovid), EMBASE, CRD Databases, Cochrane Library, and EconLit in August 2011 with updates in June 2013, April 2015, and November 2016. To assess studies systematically, a standardized form was applied to extract relevant information that was then summarized in evidence tables. RESULTS Thirty-five studies were included; 27 state-transition models were analyzed using cohort (n = 12) and individual-level simulation (n = 15). Twenty-one studies modeled the natural history of breast cancer and predicted mortality as a function of the early detection modality. The models employed different assumptions regarding ductal carcinoma in situ. Thirteen studies performed cost-utility analyses with different sources for utility values, but assumptions were often made about utility weights. Twenty-two models did not report any validation. CONCLUSION State-transition modeling was the most frequently applied analytic approach. Different methods in modeling the progression of ductal carcinoma in situ to invasive cancer were identified because there is currently no agreement on the biological behavior of noninvasive breast cancer. Main weaknesses were the lack of precise utility estimates and insufficient reporting of validation. Sensitivity analyses of assumptions regarding ductal carcinoma in situ and in particular adequate validation are critical to minimize the risk of biased model outcomes.
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Affiliation(s)
- Irmgard C Schiller-Frühwirth
- Department of Evidence-Based Economic Health Care, Main Association of Austrian Social Security Institutions, Kundmanngasse 21, 1030, Vienna, Austria.
- Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria.
| | - Beate Jahn
- Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Division of Health Technology Assessment and Bioinformatics, ONCOTYROL-Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - Marjan Arvandi
- Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Division of Health Technology Assessment and Bioinformatics, ONCOTYROL-Center for Personalized Cancer Medicine, Innsbruck, Austria
- Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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16
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Raldow AC, Sher D, Chen AB, Recht A, Punglia RS. Cost Effectiveness of the Oncotype DX DCIS Score for Guiding Treatment of Patients With Ductal Carcinoma In Situ. J Clin Oncol 2016; 34:3963-3968. [PMID: 27621393 DOI: 10.1200/jco.2016.67.8532] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Purpose The Oncotype DX DCIS Score short form (DCIS Score) estimates the risk of an ipsilateral breast event (IBE) in patients with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery without adjuvant radiation therapy (RT). We determined the cost effectiveness of strategies using this test. Materials and Methods We developed a Markov model simulating 10-year outcomes for 60-year-old women eligible for the Eastern Cooperative Oncology Group E5194 study (cohort 1: low/intermediate-grade DCIS, ≤ 2.5 cm; cohort 2: high-grade DCIS, ≤ 1 cm) with each of five strategies: (1) no testing, no RT; (2) no testing, RT only for cohort 2; (3) no RT for low-grade DCIS, test for intermediate- and high-grade DCIS, RT for intermediate- or high-risk scores; (4) test all, RT for intermediate- or high-risk scores; and (5) no testing, RT for all. We used utilities and costs extracted from the literature and Medicare claims to determine incremental cost-effectiveness ratios and examined the number of women needed to irradiate per IBE prevented. Results No strategy using the DCIS Score was cost effective. The most cost-effective strategy (RT for none or RT for all) was sensitive to small differences between the utilities of receiving or not receiving RT and remaining without recurrence. The numbers needed to irradiate per IBE prevented were 10.5, 9.1, 7.5, and 13.1 for strategies 2 to 5, respectively, relative to strategy 1. Conclusion Strategies using the DCIS Score lowered the proportion of women undergoing RT per IBE prevented. However, no strategy incorporating the DCIS Score was cost effective. The cost effectiveness of RT was exquisitely utility sensitive, highlighting the importance of engaging patient preferences in this decision. Physicians should discuss trade-offs associated with omitting or adding adjuvant RT with each patient to maximize quality-of-life outcomes.
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Affiliation(s)
- Ann C Raldow
- Ann C. Raldow, David Geffen School of Medicine at UCLA, Los Angeles, CA; Aileen B. Chen and Rinaa S. Punglia, Brigham and Women's Hospital/Dana-Farber Cancer Institute; and Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; and David Sher, University of Texas Southwestern Medical Center, Dallas, TX
| | - David Sher
- Ann C. Raldow, David Geffen School of Medicine at UCLA, Los Angeles, CA; Aileen B. Chen and Rinaa S. Punglia, Brigham and Women's Hospital/Dana-Farber Cancer Institute; and Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; and David Sher, University of Texas Southwestern Medical Center, Dallas, TX
| | - Aileen B Chen
- Ann C. Raldow, David Geffen School of Medicine at UCLA, Los Angeles, CA; Aileen B. Chen and Rinaa S. Punglia, Brigham and Women's Hospital/Dana-Farber Cancer Institute; and Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; and David Sher, University of Texas Southwestern Medical Center, Dallas, TX
| | - Abram Recht
- Ann C. Raldow, David Geffen School of Medicine at UCLA, Los Angeles, CA; Aileen B. Chen and Rinaa S. Punglia, Brigham and Women's Hospital/Dana-Farber Cancer Institute; and Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; and David Sher, University of Texas Southwestern Medical Center, Dallas, TX
| | - Rinaa S Punglia
- Ann C. Raldow, David Geffen School of Medicine at UCLA, Los Angeles, CA; Aileen B. Chen and Rinaa S. Punglia, Brigham and Women's Hospital/Dana-Farber Cancer Institute; and Abram Recht, Beth Israel Deaconess Medical Center, Boston, MA; and David Sher, University of Texas Southwestern Medical Center, Dallas, TX
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17
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Cost-effectiveness of population-based mammography screening strategies by age range and frequency. J Cancer Policy 2014. [DOI: 10.1016/j.jcpo.2014.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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18
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McCormick B. Radiation therapy for duct carcinoma in situ: who needs radiation therapy, who doesn't? Hematol Oncol Clin North Am 2013; 27:673-86, vii. [PMID: 23915738 DOI: 10.1016/j.hoc.2013.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Duct carcinoma in situ (DCIS) is a common but non-life-threatening breast cancer. Four large prospective randomized trials comparing radiation therapy (RT) with none after breast-conservation surgery have all concluded that the use of RT reduces the risk of a local recurrence (LR) in the ipsilateral breast by at least 50%. More information is needed to assess the role of antiestrogen therapy when RT is not given. When markers are validated to predict which patients will have an invasive LR versus another DCIS or no LR, it is hoped that the discussion with the patient will clarify the situation further.
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Affiliation(s)
- Beryl McCormick
- Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Dolan P, Lee H, Peasgood T. Losing sight of the wood for the trees: some issues in describing and valuing health, and another possible approach. PHARMACOECONOMICS 2012; 30:1035-49. [PMID: 22974537 DOI: 10.2165/11593040-000000000-00000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND AND OBJECTIVE The ability to value health in a way that allows the comparison of different conditions across a range of population groups is central to determining priorities in healthcare. This paper considers some of the concerns with the 'received wisdom' in valuing health--to describe it using a generic descriptive system and to value it using the hypothetical preferences of the general public. METHODS The literature on the dimensions of health that matter most to people was reviewed and this paper discusses the use of global measures of subjective well-being (SWB) as a possible alternative. New analysis of the British Household Panel Survey was conducted to explore the relationship between life satisfaction and the preference-based quality-of-life measure the SF-6D. The impact on life satisfaction of each level for each dimension of the SF-6D is estimated through a linear model predicting life satisfaction with the SF-6D levels as determinants. RESULTS Valuing changes in the health of the general population via changes in life satisfaction would lead to different weights being attached to the different dimensions of health, as compared to a well used utility score in which weights are taken from general population preferences. If preferences elicited via standard gamble exercises are based only on a prediction of what it would be like to live in a particular health state, then these results suggest that reductions in physical functioning matter less than people imagine and reductions in mental health impact upon our lives more than preferences would suggest. CONCLUSIONS Using data from the British Household Panel Survey, it is shown that a focus on SWB would place greater emphasis on mental health conditions. The implications for health policy are considered.
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20
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Peasgood T, Ward SE, Brazier J. Health-state utility values in breast cancer. Expert Rev Pharmacoecon Outcomes Res 2011; 10:553-66. [PMID: 20950071 DOI: 10.1586/erp.10.65] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Health-related quality of life is an important issue in the treatment of breast cancer and health-state utility values are essential for cost-utility analysis. A literature review was conducted to identify published values for common health states for breast cancer. In total, 13 databases were searched and 49 articles were identified providing 476 unique utility values. Where possible mean utility estimates were pooled using ordinary least squares with utilities clustered within study group and weighted by both number of respondents and inverse of the variance of each utility. Regressions included controls for disease state, utility assessment method and other features of study design. Utility values found in the review were summarized for six categories: screening-related states; preventative states; adverse events in breast cancer and its treatment; nonspecific breast cancer; metastatic breast cancer states; and early breast cancer states. The large number of values identified for metastatic breast cancer and early breast cancer states enabled data to be synthesized by meta-regression. Utilities were found to vary significantly between valuation methods and depending on who conducted the valuation. For metastatic breast cancer, values significantly varied by severity of condition, treatment and side-effects. Despite the numerous studies it is not feasible to generate a definitive list of health-state utility values that can be used in future economic evaluations owing to the complexity of the health states involved and the variety of methods used to obtain values. Future research into quality of life in breast cancer should make greater use of validated generic preference-based measures for which public preferences exist.
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Affiliation(s)
- Tessa Peasgood
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
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Wang SY, Kuntz K, Tuttle T, Kane R. Incorporating margin status information in treatment decisions for women with ductal carcinoma in situ: a decision analysis. Breast Cancer Res Treat 2010; 124:393-402. [PMID: 20848183 DOI: 10.1007/s10549-010-1166-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 09/03/2010] [Indexed: 10/19/2022]
Abstract
To integrate margin status information into the decision to undergo radiation therapy (RT) following breast-conserving surgery (BCS) for women with ductal carcinoma in situ (DCIS). We developed a decision-analytic Markov model to project quality-adjusted life years (QALYs) for a hypothetical cohort of 55-year-old women with DCIS over a lifetime horizon treated with or without RT following BCS. We estimated the transition probabilities of local DCIS and invasive recurrences based on the margin status (free, close, or positive) from a systematic literature review. Other probability estimates and utilities were collected from the published literature. Using the conditions defined in this model, expected QALYs after BCS alone were better than those after BCS with RT under the free-margin scenario (15.72 vs. 15.58) and worse in the close-margin (15.44 vs. 15.50) and positive-margin scenarios (15.20 vs. 15.33). The probability of receiving a salvage mastectomy varied from 10 to 28%, depending on margin status and treatment. One-way sensitivity analyses showed that the optimal treatment was sensitive to patients' preferences and RT side effects. Probabilistic sensitivity analyses revealed that BCS alone would be the best strategy in 54% of the cases under the free-margin scenario, 48% under the close-margin scenario, and 44% under the positive-margin scenario. This study illustrates that margin status is able to provide supplementary information on the decision of DCIS treatment. Our analyses also highlight the importance of patients' preferences in decision making. Our findings suggest that RT is not necessary for all patients with DCIS undergoing BCS.
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Affiliation(s)
- Shi-Yi Wang
- Department of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware Street S.E. MMC 729, Minneapolis, MN 55455, USA.
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Jugenburg M, Disa JJ, Pusic AL, Cordeiro PG. Impact of Radiotherapy on Breast Reconstruction. Clin Plast Surg 2007; 34:29-37; abstract v-vi. [PMID: 17307069 DOI: 10.1016/j.cps.2006.11.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Breast reconstruction in the face of radiotherapy poses a unique set of challenges to the plastic surgeon and thus alters the algorithm of the reconstruction. The impact of radiation changes on alloplastic and autologous breast reconstruction is unpredictable. This article reviews the pathophysiology of radiation changes and the alterations to the reconstructive process.
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Affiliation(s)
- Martin Jugenburg
- Plastic and Reconstructive Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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