Evaluating Consensus Among Physicians in Medical Knowledge Base Construction

This study evaluates inter-author variability in knowledge base construction. Seven board-certified internists independently profiled “acute perinephric abscess”, using as reference material a set of 109 peer-reviewed articles. Each participant created a list of findings associated with the disease, estimated the predictive value and sensitivity of each finding, and assessed the pertinence of each article for making each judgment. Agreement in finding selection was significantly different from chance: seven, six, and five participants selected the same finding 78.6, 9.8, and 1.6 times more often than predicted by chance. Findings with the highest sensitivity were most likely to be included by all participants. The selection of supporting evidence from the medical literature was significantly related to each physician’s agreement with the majority. The study shows that, with appropriate guidance, physicians can reproducibly extract information from the medical literature, and thus established a foundation for multi-author knowledge base construction.

Is cancer care best at high-volume providers?

For a variety of medical conditions and procedures, a higher volume-better outcome relationship has been hypothesized for over 25 years. An extensive, consistent body of literature supports a relationship between hospital volume and short-term outcomes for cancers treated with technologically complex surgical procedures. For cancer primarily treated by low-risk surgery, there are few studies. Recent studies found a modest (about 2%) difference in survival benefit between high-volume and low-volume providers associated with colon cancer surgery. Few evaluations in the last 15 years have addressed nonsurgical cancers, eg, lymphomas and testicular cancer. No reports have addressed recurrent or metastatic cancer. Care is better at high-volume providers for a select minority of cancers. Whether provider volume matters in the majority of cancers at the time of presentation has not been evaluated.

Pharmacoeconomic issues in bisphosphonate treatment of metastatic bone disease

Bisphosphonates provide a supportive benefit to patients with bone metastases from cancer by reducing skeletal complications, such as bone pain, pathologic fractures, and hypercalcemia. Although bisphosphonates have important therapeutic effects, such as significant improvements in the quality of remaining life, they do not, as yet, significantly improve the overall survival of affected patients. Furthermore, as with all new innovations, they exert a major impact on drug budgets dedicated for cancer care. Further research is warranted to identify clinical predictors of the optimum time in the course of the disease to start and stop therapy, to integrate use of bisphosphonates with other therapies, to identify their role in the adjuvant setting, and to determine their cost-benefit consequences. Current cost-effectiveness assessments have shown that the incremental costs per skeletal-related event are particularly sensitive to the unit price of the bisphosphonate modeled. Therefore, pharmacoeconomic evaluations should be combined with clinical trials to predict accurately the true costs (total resource usage) of this health care intervention and to ultimately assess the rational broad use of these agents.

Ensuring quality cancer care by the use of clinical practice guidelines and critical pathways

PURPOSE

We describe the impact of clinical practice guidelines (CPGs) on improvement in oncology treatment processes or outcomes.

METHODS

We performed a comprehensive search of the literature from 1966 to the present and a directed review of the literature.

RESULTS

Improvements have been demonstrated in compliance with evidence-based guidelines or evidence-based medicine, and in short-term length of stay, complication rates, and financial outcomes. The data suggest that patient satisfaction can be maintained despite a shorter length of stay. There has been one example of province-wide improvement in disease-free and overall survival of breast cancer patients coincident with the adoption of CPGS: The components of successful guidelines can be summarized as follows: (1) development is based on evidence, with the guideline formulated by key physicians in the group; (2) the guidelines are disseminated to all affected health care professionals for critique; (3) implementation includes direct feedback on performance to physicians or general feedback on system performance; and (4) there is accountability for performance according to the guidelines. This accountability can consist of voluntary peer pressure to conform to evidence-based medicine, and it does not require a financial reward or penalty.

CONCLUSION

Some attempts to improve practice have been moderately successful in achievement of reduced health care costs, reduced hospital length of stay, and possibly improved outcomes. Other methods that are still in use have been demonstrated to have little effect. Programs that have not succeeded have relied on voluntary change in practice behavior without incentives to change or have had no accountability component. Further research is needed to assess how guidelines are enacted in organizations other than those demonstrably committed to improvement, ways to improve compliance of health care providers who are not committed to change, and methods to improve accountability.

Burden of illness associated with metastatic melanoma: an audit of 100 consecutive referral center cases

BACKGROUND

Although long-term survival in patients with metastatic melanoma (MM) is infrequent, response to a variety of cytotoxic and immunotherapies occurs and survival varies based on the site of metastases. Because different patterns of care of MM are likely to vary substantially in their intensity and resource use, the authors audited care at a regional referral center.

METHODS

The records of 100 consecutive new patients with MM who presented at the University of Pittsburgh Cancer Institute (UPCI) after January 1997 were audited. Demographics, disease sites, and treatment prior to presentation at UPCI as well as the diagnostic and therapeutic methods undertaken at UPCI were tracked monthly with regard to inpatient and outpatient activity.

RESULTS

The median age of the patient cohort was 51 years was a median 2.2 years after the time of initial diagnosis. Eighty-two percent of the patients had died and only 8% had been lost to long-term follow-up. Eighty-seven percent of patients had been referred to UPCI and 28% had received some treatment prior to presenting at UPCI. The median survival was 9.0 months. The lung was the most common symptomatic site and 38% of patients developed central nervous system (CNS) metastases. Eighty-four percent of patients initially were treated on a research protocol 30% of whom were part of a Phase III study. Twenty-nine percent of the patients were never hospitalized. The most common reason for hospitalization was elective treatment with high-dose interleukin-2. Lifetime hospital days averaged only 7.3 days. Therapeutic actions (if ever given) by category type were surgery in 23% of patients, radiation therapy in 44%, immunotherapy in 75%, and chemotherapy in 51%. Using assigned values for the identified resources used, the approximate cost per patient averaged $59,400.

CONCLUSIONS

The current audit of MM patients demonstrated that lung and CNS metastases dominate a broad variety of complications, that clinical trial participation was the norm, that hospitalizations occurred relatively infrequently, and that the direct health care costs of current treatment patterns are among the highest for all malignancies. Medical auditing of contemporary American cancer care provides meaningful insights into its patterns of care.

Cost-effectiveness analysis of exemestane compared with megestrol in patients with advanced breast carcinoma

BACKGROUND

The objective of this study was to determine the potential economic implications resulting from using exemestane (EXE), a new steroidal, irreversible aromatase inactivator, compared with megestrol acetate (MA) in patients with advanced breast carcinoma.

METHODS

The model used the clinical results from the manufacturer-sponsored, international, randomized, controlled, double-blind trial of patients with postmenopausal, tamoxifen-refractory advanced breast carcinoma. Seven hundred sixty-nine women were randomized to EXE 25 mg per day or MA 40 mg four times daily EXE was well tolerated, significantly delayed tumor progression (relative risk [RR], 0.82; 95% confidence interval [95% CI], 0.70-0.97), and prolonged survival (RR, 0.77; 95% CI, 0.59-0.99). Lifetime effectiveness projections were made using the trial efficacy results to the U.S. market using a 1000-day ( approximately 3-year) time frame. Because the median survival of patients who received EXE was not reached, it was projected from the Cox model. There were no differences in the rate of hospitalization. The average wholesale prices for EXE and MA were used.

RESULTS

Patients who received EXE were projected to have a mean survival benefit of 53.5 days (estimated 95% CI, 2-100 days) and to incur at an additional cost of $1559 per patient (estimated 95% CI, 880-2075 dollars). The incremental cost effectiveness (CE) ratio using EXE was 10,600 dollars per life year gained (estimated 95% CI, 6200-209,000 dollars). If MA had no costs, then the CE ratio increased to 12,200 dollars per life year. Using a 5-year projection, the CE ratio for EXE was 5900 dollars per life year. The projected survival at 1000 days was 53.9% in the EXE cohort compared with 44.8% in the MA cohort.

CONCLUSIONS

EXE, compared with MA, is projected to increase survival at a modest added cost. If treatment with EXE delays or defers initiating more costly therapies, then it may even be cost saving.

The role of bisphosphonates in metastatic breast cancer

The American Society of Clinical Oncology has recently developed guidelines for the use of bisphosphonates in breast cancer. Highlights of these guidelines are reviewed. Specific issues addressed included when in the course of disease should treatment be started, the duration of therapy, the role of bisphosphonates in pain control, their safety, and current estimates of their cost effectiveness. Although intravenous bisphosphonates, primarily pamidronate, have been shown to reduce the frequency of skeletal-related complications in women with known lytic bone metastases from breast cancer, numerous major areas of clinical importance related to their use have not been studied and are highlighted.

Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care

PURPOSE

To conduct a comprehensive review of the health services literature to search for evidence that hospital or physician volume or specialty affects the outcome of cancer care.

METHODS

We reviewed the 1988 to 1999 MEDLINE literature that considered the hypothesis that higher volume or specialization equals better outcome in processes or outcomes of cancer treatments.

RESULTS

An extensive, consistent literature that supported a volume-outcome relationship was found for cancers treated with technologically complex surgical procedures, eg, most intra-abdominal and lung cancers. These studies predominantly measured in-hospital or 30-day mortality and used the hospital as the unit of analysis. For cancer primarily treated with low-risk surgery, there were fewer studies. An association with hospital and surgeon volume in colon cancer varied with the volume threshold. For breast cancer, British studies found that physician specialty and volume were associated with improved long-term outcomes, and the single American report showed an association between hospital volume of initial surgery and better 5-year survival. Studies of nonsurgical cancers, principally lymphomas and testicular cancer, were few but consistently showed better long-term outcomes associated with larger hospital volume or specialty focus. Studies in recurrent or metastatic cancer were absent. Across studies, the absolute benefit from care at high-volume centers exceeds the benefit from break-through treatments.

CONCLUSION

Although these reports are all retrospective, rely on registries with dated data, rarely have predefined hypotheses, and may have publication and self-interest biases, most support a positive volume-outcome relationship in initial cancer treatment. Given the public fear of cancer, its well-defined first identification, and the tumor-node-metastasis taxonomy, actual cancer care should and can be prospectively measured, assessed, and benchmarked. The literature suggests that, for all forms of cancer, efforts to concentrate its initial care would be appropriate.

Post hoc economic analysis of temozolomide versus dacarbazine in the treatment of advanced metastatic melanoma

PURPOSE

To determine the potential economic implications resulting from oral temozolomide (TEM) compared with intravenous (IV) dacarbazine (DTIC) for metastatic melanoma.

PATIENTS AND METHODS

We performed a cost-effectiveness (CE) analysis using hazard ratios (HRs) from the phase III (Schering I95-018) trial comparing TEM 200 mg/m(2)/d orally for 5 days every 28 days with DTIC 250 mg/m(2)/d IV for 5 days every 21 days. Sensitivity analyses assessed a range of TEM's efficacy and costs, direct nonmedical costs, and the DTIC schedule.

RESULTS

The trial found an overall survival trend favoring TEM; median survival times of patients treated with DTIC and TEM were 6.4 and 7.7 months, respectively (HR = 1.18; 95% confidence interval [CI], 0.92 to 1.52; intention to treat, P =.20). The mean increase in survival of TEM over DTIC was 1.1 months. The projected average costs per patient were greater with TEM than DTIC ($6,902 v $3,697, respectively). The incremental CE ratio using TEM was $36,990 per life-year or $101 per day of life gained. The CE ratio's 95% CI ranged from -$65,180 (DTIC is more effective) to $18, 670 per year of life gained. The CE ratios decreased 50% if direct nonmedical costs were included and increased 50% if DTIC's efficacy was unchanged if given as a single daily dosage. Sixty percent of simulations found TEM with a CE threshold of less than $50,000 per life-year gained.

CONCLUSION

Although the base-case efficacy of TEM compared with DTIC was not statistically significant, its associated incremental CE would be comparable with many interventions. TEM for metastatic melanoma illustrates the tension confronting providers choosing between similar agents that markedly differ in convenience and costs.

American Society of Clinical Oncology guideline on the role of bisphosphonates in breast cancer. American Society of Clinical Oncology Bisphosphonates Expert Panel

PURPOSE

To determine clinical practice guidelines for the use of bisphosphonates in the prevention and treatment of bone metastases in breast cancer and their role relative to other therapies for this condition.

METHODS

An expert multidisciplinary panel reviewed pertinent information from the published literature and meeting abstracts through May 1999. Additional data collected as part of randomized trials and submitted to the United States Food and Drug Administration were also reviewed, and investigators were contacted for more recent information. Values for levels of evidence and grade of recommendation were assigned by expert reviewers and approved by the panel. Expert consensus was used if there were insufficient published data. The panel addressed which patients to treat and when in their course of disease, specific drug delivery issues, duration of therapy, management of bony metastases with other therapies, and the public policy implications. The guideline underwent external review by selected physicians, members of the American Society of Clinical Oncology (ASCO) Health Services Research Committee, and the ASCO Board of Directors.

RESULTS

Bisphosphonates have not had an impact on the most reliable cancer end point: overall survival. The benefits have been reductions in skeletal complications, ie, pathologic fractures, surgery for fracture or impending fracture, radiation, spinal cord compression, and hypercalcemia. Intravenous (IV) pamidronate 90 mg delivered over 1 to 2 hours every 3 to 4 weeks is recommended in patients with metastatic breast cancer who have imaging evidence of lytic destruction of bone and who are concurrently receiving systemic therapy with hormonal therapy or chemotherapy. For women with only an abnormal bone scan but without bony destruction by imaging studies or localized pain, there is insufficient evidence to suggest starting bisphosphonates. Starting bisphosphonates in patients without evidence of bony metastasis, even in the presence of other extraskeletal metastases, is not recommended. Studies of bisphosphonates in the adjuvant setting have yielded inconsistent results. Starting bisphosphonates in patients at any stage of their nonosseous disease, outside of clinical trials, despite a high risk for future bone metastasis, is currently not recommended. Oral bisphosphonates are one of several options which can be used for preservation of bone density in premenopausal patients with treatment-induced menopause. The panel suggests that, once initiated, IV bisphosphonates be continued until evidence of substantial decline in a patient's general performance status. The panel stresses that clinical judgment must guide what is a substantial decline. There is no evidence addressing the consequences of stopping bisphosphonates after one or more adverse skeletal events. Symptoms in the spine, pelvis, or femur require careful evaluation for spinal cord compression and pathologic fracture before bisphosphonate use and if symptoms recur, persist, or worsen during therapy. The panel recommends that current standards of care for cancer pain, analgesics and local radiation therapy, not be displaced by bisphosphonates. IV pamidronate is recommended in women with pain caused by osteolytic metastasis to relieve pain when used concurrently with systemic chemotherapy and/or hormonal therapy, since it was associated with a modest pain control benefit in controlled trials.

CONCLUSION

Bisphosphonates provide a meaningful supportive but not life-prolonging benefit to many patients with bone metastases from cancer. Further research is warranted to identify clinical predictors of when to start and stop therapy, to integrate their use with other treatments for bone metastases, to identify their role in the adjuvant setting in preventing bone metastases, and to better determine their cost-benefit consequences.

Tamoxifen should be cost-effective in reducing breast cancer risk in high-risk women

PURPOSE

To estimate the cost-effectiveness of tamoxifen in the prevention of breast cancer.

PATIENTS AND METHODS

Clinical trial results of National Surgical Adjuvant Breast Program P-1 compared tamoxifen versus placebo in the prevention of breast cancer, and direct medical care costs were estimated from the Agency for Health Care Policy and Research and local sources. The base estimate of effectiveness included all women on the trial.

RESULTS

For every 100 women treated for 5 years, 1.665 expected cancers would not be detected. If breast cancer death is fully prevented by this strategy, then the cost-effectiveness of tamoxifen compared with no intervention is $8,479 per additional year of life gained. If lifetime prevention of the risk of death from breast cancer exceeded 17%, then the cost-effectiveness ratio would be less than $50,000 per year of life gained (a common benchmark).

CONCLUSIONS

Tamoxifen for breast cancer prevention should be cost-effective under nearly all circumstances. Its use will require additional resources because it is not cost saving, but it fits within accepted guidelines.

Pamidronate in prevention of bone complications in metastatic breast cancer: a cost-effectiveness analysis

PURPOSE

Pamidronate is effective in reducing bony complications in patients with metastatic breast cancer who have known osteolytic lesions. However, pamidronate does not increase survival and is associated with additional financial costs and inconvenience. We conducted a post-hoc evaluation of the cost-effectiveness of pamidronate using the results of two randomized trials that evaluated pamidronate 90 mg administered intravenously every month versus placebo.

PATIENTS AND METHODS

The trials differed only in the initial systemic therapy administered (hormonal or chemotherapy). Total skeletal related events (SREs), including surgery for pathologic fracture, radiation for fracture or pain control, conservatively treated pathologic fracture, spinal cord compression, or hypercalcemia, were taken directly from the trials. Using a societal perspective, direct health care costs were assigned to each SRE. Each group's monthly survival was equal and was projected to decline using observed median survivals. The cost of pamidronate reflected the average wholesale price of the drug plus infusion. The value or disutility of an adverse event per month was evaluated using a zero value (events avoided) or an assigned one (range, 0.2 to 0.8).

RESULTS

The cost of pamidronate therapy exceeded the cost savings from prevented adverse events. The difference between the treated and placebo groups was larger with hormonal systemic therapy than with chemotherapy (additional $7,685 compared with $3,968 per woman). The projected net cost per SRE avoided was $3,940 with chemotherapy and $9,390 with hormonal therapy. The cost-effectiveness ratios were $108,200 with chemotherapy and $305, 300 with hormonal therapy per quality-adjusted year.

CONCLUSION

Although pamidronate is effective in preventing a feared, common adverse outcome in metastatic breast cancer, its use is associated with high incremental costs per adverse event avoided. The analysis is most sensitive to the costs of pamidronate and pathologic fractures that were asymptomatic or treated conservatively.

Cost-effectiveness of adding an electron-beam boost to tangential radiation therapy in patients with negative margins after conservative surgery for early-stage breast cancer

PURPOSE

Electron-beam boosts (EBB) are routinely added after conservative surgery and tangential radiation therapy (TRT) for early-stage breast cancer. We performed an incremental cost-utility analysis to evaluate their cost-effectiveness.

METHODS

A Markov model examined the impact of adding an EBB to TRT from a societal perspective. Outcomes were measured in quality-adjusted life years (QALYs). On the basis of the Lyon trial, the EBB was assumed to reduce local recurrences by approximately 2% at 10 years but to have no impact on survival. Patients' utilities were used to adjust for quality of life. Given the small absolute benefit of the EBB, baseline utilities were assumed to be the same with or without it, an assumption evaluated by Monte Carlo simulation. Direct medical, time, and travel costs were considered.

RESULTS

Adding the EBB led to an additional cost of $2,008, an increase of 0.0065 QALYs and, therefore, an incremental cost-effectiveness ratio of over $300,000/QALY. In a sensitivity analysis, the ratio was moderately sensitive to the efficacy and cost of the EBB and highly sensitive to patients' utilities for treatment without it. Even if patients do value a small risk reduction, the mean cost-effectiveness ratio estimated by the Monte Carlo simulation remains high, at $70,859/QALY (95% confidence interval, $53,141 to $105,182/QALY).

CONCLUSION

On the basis of currently available data, the cost-effectiveness ratio for the EBB is well above the commonly cited threshold for cost-effective care ($50,000/QALY). The EBB becomes cost-effective only if patients place an unexpectedly high value on the small absolute reduction in local recurrences achievable with it.

Is the use of radiation therapy after mastectomy cost-effective?

With the publication of two randomized trials showing an improvement in overall survival after the use of postmastectomy radiation therapy, interest in the use of radiation therapy in this setting has been rekindled. These results are in contrast to those reported in the most recent meta-analysis of the Early Breast Cancer Trialists' Collaborative Group, in which a statistically significant survival benefit was not detected. Although evidence of a survival benefit was sufficient in the past for an intervention to gain acceptance, payers are increasingly interested in knowing whether its use is also cost-effective. This article briefly reviews the methods used in performing cost-effectiveness analyses, summarizes the results of one published and a second preliminary cost-effectiveness analysis of postmastectomy radiation therapy, and highlights several areas for future research.

Predictors of Medicare costs in elderly beneficiaries with breast, colorectal, lung, or prostate cancer

BACKGROUND

Determining the apportionment of costs of cancer care and identifying factors that predict costs are important for planning ethical resource allocation for cancer care, especially in markets where managed care has grown.

DESIGN

This study linked tumor registry data with Medicare administrative claims to determine the costs of care for breast, colorectal, lung and prostate cancers during the initial year subsequent to diagnosis, and to develop models to identify factors predicting costs.

SUBJECTS

Patients with a diagnosis of breast (n = 1,952), colorectal (n = 2,563), lung (n = 3,331) or prostate cancer (n = 3,179) diagnosed from 1985 through 1988.

RESULTS

The average costs during the initial treatment period were $12,141 (s.d. = $10,434) for breast cancer, $24,910 (s.d. = $14,870) for colorectal cancer, $21,351 (s.d. = $14,813) for lung cancer, and $14,361 (s.d. = $11,216) for prostate cancer. Using least squares regression analysis, factors significantly associated with cost included comorbidity, hospital length of stay, type of therapy, and ZIP level income for all four cancer sites. Access to health care resources was variably associated with costs of care. Total R2 ranged from 38% (prostate) to 49% (breast). The prediction error for the regression models ranged from < 1% to 4%, by cancer site.

CONCLUSIONS

Linking administrative claims with state tumor registry data can accurately predict costs of cancer care during the first year subsequent to diagnosis for cancer patients. Regression models using both data sources may be useful to health plans and providers and in determining appropriate prospective reimbursement for cancer, particularly with increasing HMO penetration and decreased ability to capture complete and accurate utilization and cost data on this population.

Is the use of radiation therapy after mastectomy cost-effective?

With the publication of two randomized trials showing an improvement in overall survival after the use of postmastectomy radiation therapy, interest in the use of radiation therapy in this setting has been rekindled. These results are in contrast to those reported in the most recent meta-analysis of the Early Breast Cancer Trialists' Collaborative Group, in which a statistically significant survival benefit was not detected. Although evidence of a survival benefit was sufficient in the past for an intervention to gain acceptance, payers are increasingly interested in knowing whether its use is also cost-effective. This article briefly reviews the methods used in performing cost-effectiveness analyses, summarizes the results of one published and a second preliminary cost-effectiveness analysis of postmastectomy radiation therapy, and highlights several areas for future research.

A sociodemographic and economic comparison of breast reconstruction, mastectomy, and conservative surgery

BACKGROUND

There are a variety of surgical choices for women with early-stage breast cancer, including breast-conserving surgery, mastectomy, or mastectomy plus reconstructive surgery. This report examines some of the factors that affect these choices and the costs of the various treatment options.

METHODS

Data from the Virginia Cancer Registry were linked to insurance claims from the Trigon Blue Cross and Blue Shield Company for women with local and regional staged breast cancer from 1989 to 1991 in Virginia. Multivariate analyses and cost studies were performed.

RESULTS

There were 592 women who underwent breast-conserving surgery (BCS, 26%), mastectomy (58%), or mastectomy plus reconstruction (16%). Increasing age reduced the use of reconstruction. The choice of reconstruction was not affected by tumor size, nodal status, or race. Sixty percent of women had immediate breast reconstruction at the time of mastectomy; the majority had the implant procedure. The cost of BCS ($21,582) was higher than that of mastectomy ($16,122, P < .01). The costs for BCS and mastectomy were significantly lower than for mastectomy plus reconstruction ($31,047, P < .05). The 2-year cost for immediate reconstruction was $8200 less than for delayed procedures and was similar to the cost of BCS.

CONCLUSIONS

Age was the driving force in reconstruction decisions. Clinical factors such as tumor size and nodal status were more important for the choice between BCS and mastectomy. There are significant cost differences between the various procedures. For a similar cosmetic outcome, BCS is less expensive than breast reconstruction. When reconstruction is required, a simultaneous procedure is less expensive.

Review of cost-effectiveness assessments of chemotherapy in adjuvant and advanced breast cancer

Economic assessments of treatment alternatives in breast cancer have been predominantly ones addressing the role and type of adjuvant therapy. These assessments have shown that the effectiveness of the intervention drives the cost-effectiveness results. Other key factors were the relative risk of recurrence, the time frame considered and only minimally the costs of the intervention. Assessments in advanced breast cancer are few in parallel with the limited number of phase III trials. Future assessments should address neoadjuvant therapy, high-dose adjuvant therapy and agents that alter disease associated complications agents such as biphosphonates.

A comparison of patterns of care of nonsmall cell lung carcinoma patients in a younger and Medigap commercially insured cohort

BACKGROUND

The objective of this study was to examine and compare lifetime treatment patterns and hospitalization of incident nonsmall cell lung carcinoma (NSCLC) between pre-Medicare eligible (age < 65 years) and supplemental Medigap (age > or = 65 years) enrollees in a commercially insured cohort using insurance claims.

METHODS

Claims from Virginia Blue Cross and Blue Shield beneficiaries with NSCLC submitted between 1989-1991 were merged with records from the Virginia Cancer Registry (VCR). Data from the VCR identified incident cases, disease stage, and type of tumor. Initial treatment categories were stratified using Physicians' Current Procedural Terminology codes.

RESULTS

There were 1706 incident NSCLC patients; 349 were age < or = 64 years ("younger") and 1212 were age > or = 65 years ("elderly"). Having commercial insurance was not associated with any survival advantage compared with national averages at 2 years. In comparison with elderly patients, younger patients more often were treated with surgery for local disease (80.2% vs. 54.8%) and surgery alone or in combination with radiation for regional disease (51.9% vs. 32.0%). Radiation was used more often in elderly patients compared with younger patients with local disease (30.5% vs. 14.0%) but less often in patients with distant disease (76.2% vs. 54.9%). Compared with elderly patients, younger patients presenting with distant disease received more chemotherapy (18.8% vs. 5.1%; P <0.001); late palliative use of chemotherapy or radiation occurred in only 4-8% of younger patients. Compared with elderly patients, younger patients with regional or distant disease spent more days in the hospital (compared with national averages at 2 years: regional disease, 30.0 vs. 23.9 days; distant disease, 33.0 vs. 21.4 days; P <0.0001).

CONCLUSIONS

The results of this study show that more comprehensive health insurance is not associated with better outcomes in patients with NSCLC. Age specific trends for greater use of surgery, radiation, and total hospitalization in younger patients is consistent with other reports. Commercial health care claims supplemented by clinical staging from cancer registries can address long term practice patterns in patients with cancer.

Cost-effectiveness assessment of interferon alfa-2b as adjuvant therapy of high-risk resected cutaneous melanoma

The use of interferon alfa-2b (IFN-alpha 2b) as adjuvant therapy of high-risk resected cutaneous melanoma was recently found to significantly improve relapse-free and overall survival in the Eastern Cooperative Oncology Group trial 1684 (E1684). However, treatment toxicities and costs may limit its widespread use. A cost-effectiveness and cost-utility analysis of this therapy was conducted using a hypothetical cohort of patients as if they had entered E1684. Survival and recurrence rates were calculated at 7 and 35 years for typical 50-year-old melanoma patients based on the clinical results of E1684 and natural history databases. Costs included all treatment-related costs (i.e. drug acquisition and administration, monitoring and treatment-related toxicity) and the costs of treating recurrences. Estimated utility values were assigned based on data from other oncology trials. The model predicted that IFN-alpha 2b provided an extra 0.52 years of life compared with observation at 7 years; however, at 35 years, the survival benefit of IFN-alpha 2b increased almost 4-fold to nearly 2 years. At 7 years, the cost per year of life gained was U.S. $32,600 and the cost per quality-adjusted life-year (QALY) gained was U.S. $43,200. At 35 years, these costs decreased to U.S. $13,700 and $15,200, respectively. These costs are comparable with those of other well-established medical interventions. Although these results require confirmation in a prospective study, it appears that the use of high-dose IFN-alpha 2b for patients with high-risk melanoma is cost-effective.

Costs of care associated with non-small-cell lung cancer in a commercially insured cohort

PURPOSE

To examine the cost of incident cases of non-small-cell lung cancer (NSCLC) in a commercially insured cohort.

METHODS

Claims from Virginia Blue Cross and Blue Shield (BCBS) beneficiaries with lung cancer from 1989 to 1991 were merged with records from the Virginia Cancer Registry (VCR). Data from the VCR identified incident cases, stage, and type of cancer at diagnosis. Costs for all medical care included insurance payment, copayments, and deductibles for 2 years after diagnosis or until death.

RESULTS

Three hundred forty-nine incident NSCLC patients were evaluated. The mean 2-year cost for each patient after diagnosis or until death was $47,941 (95% confidence interval, $43,758 to $52,124). Total average costs and hospital days were significantly lower for local disease ($37,514, 21.2 days), but were similar for regional ($52,797, 30.0 days) and distant ($49,382, 33.0 days) disease. Hospital days accounted for 48% and hospital-based claims for 70% of costs. Initial treatments, which included radiation, unadjusted for stage, had the lowest survival rates and the highest costs, and were associated with the most hospital days. Initial stage, race, gender, and age were not predictors of total 2-year costs. The independent predictors of total 2-year costs were type of treatment: any radiation therapy, any surgery, or any chemotherapy (all, P < .001). Inpatient hospital days was only a modest predictor of costs after adjusting for type of treatment. Patients who survived less than 1 year spent 30.5 days in hospital and had an average cost of $47,280.

CONCLUSION

The direct health care costs of younger NSCLC patients care are substantial. These results should serve as a benchmark for future comparisons as the United States market shifts to managed care.

Overview of economic analysis of Le Chevalier Vinorelbine Study

The costs and relative cost-effectiveness of different treatments for common illnesses are an increasing concern. New treatments for advanced non-small-cell lung cancer are having an impact. However, these treatments vary markedly in their direct financial costs, toxicity, and quality-of-life profiles. Direct comparisons between most combination regimens are not yet completed. Vinorelbine (Navelbine) is the first new agent approved in the United States for the treatment of metastatic non-small-cell lung cancer in more than a decade. We previously reported results of a post-hoc economic analysis that compared the anticipated cost-effectiveness of three regimens used to treat non-small-cell lung cancer (vinorelbine alone versus vinorelbine plus cisplatin [Platinol] versus vindesine plus cisplatin, the assumed standard treatment in Europe). Results showed that vinorelbine plus cisplatin was the most effective regimen. Using vinorelbine alone as a baseline, vinorelbine plus cisplatin added 56 days of life at an additional cost of $2,700, resulting in a cost-effectiveness ratio of $17,700 per year of life gained. Similarly, vindesine plus cisplatin added 19 days of life at a cost of $1,150, or $22,100 per year of life gained. Compared to vindesine plus cisplatin, vinorelbine plus cisplatin added 37 days of life at a cost of $1,570, or $15,500 per year of life gained. We conclude that the incremental cost-effectiveness of the vinorelbine plus cisplatin regimen was less than most commonly accepted medical interventions. If vinorelbine is preferred because of its favorable toxicity profile, the additional effectiveness of cisplatin added substantial efficacy at an acceptable cost.

Cost-effectiveness of routine radiation therapy following conservative surgery for early-stage breast cancer

PURPOSE

To examine the cost-effectiveness of radiation therapy following conservative surgery for early-stage breast cancer.

METHODS

Using a Markov model, a cost-utility analysis was performed to compare a strategy of radiation therapy versus no radiation therapy in a hypothetical cohort of 60-year-old women following conservative surgery. Local recurrence, distant recurrence, and survival rates used in the model were derived from randomized trial data. Utilities for the nonmetastatic health states were collected from actual patients. Direct medical costs were estimated using data from a single institution. Transportation and time costs were also estimated. Years of life, quality-adjusted life-years (QALYs), costs, and incremental cost/QALY over a 10-year time horizon were calculated by the model for each strategy.

RESULTS

The addition of radiation therapy results in a cost increase of $9,800 per patient, no change in life expectancy, and an increase of 0.35 QALYs per patient, which leads to an incremental cost-effectiveness ratio of $28,000/QALY, which is well below $50,000/QALY, a commonly cited threshold for cost-effective care. Sensitivity analysis shows the ratio to be heavily influenced by the cost of radiation therapy and the quality-of-life benefit that results from decreased risk of local recurrence.

CONCLUSION

Radiation therapy following conservative surgery is cost-effective compared with other accepted medical interventions. This study illustrates the importance of considering an intervention's effect on quality of life, as well as survival in defining cost-effectiveness.

Decision analysis: MIBI imaging of nonpalpable breast abnormalities

Scintimammography using sestamibi has provided exciting preliminary results in evaluating suspicious breast lesions. A computer simulation was performed using projected test characteristics to guide future studies and to evaluate the clinical and financial consequences of the anticipated use of noninvasive breast evaluation strategies.

METHODS

A decision analysis model compared sestamibi breast imaging, stereotaxic core biopsy and surgical biopsy as breast evaluation strategies for hypothetical cohorts of 1000 women with nonpalpable breast lesions. All women with a negative original procedure would have a 6-mo follow-up. Sensitivity and specificity were estimated from the literature and from a recent multicenter assessment for sestamibi. Probabilities of 10% for both invasive cancer and in situ cancer were based on mammographic features. Costs were based on the costs incurred by patients who were evaluated at our institution and the costs of sestamibi projections.

RESULTS

Per 1000 women, core biopsy was projected to miss about seven invasive and 10 in situ cancers more than would surgery. Sestamibi imaging was projected to miss an additional 16 invasive cancers and 12 in situ cancers, compared to core biopsy. Most misses would be detected at 6-mo follow-up. Compared to immediate surgery, the cost would be reduced by 20% with the core biopsy and 39% with the sestamibi strategy. Sixty-five percent of women having sestamibi imaging would avoid any invasive biopsy. The projected cost savings of core biopsy or sestamibi imaging, compared to surgery, ranged fom $17,700 to $77,500 per delayed cancer diagnosis.

CONCLUSION

If sestamibi imaging has similar test characteristics outside the research setting, then sestamibi imaging or sterotaxic core biopsy will lead to substantial cost savings compared to surgery with a slight compromise in the rate of early cancer detection. A decision analysis simulation can aid in designing clinical trials and exploring new strategies. The adopting of nonsurgical biopsy techniques will likely depend on confirming or establishing their test characteristics in lower-risk lesions, the natural history of cancers whose diagnosis is delayed and patient preferences of the value on avoiding any form of breast biopsy.

Economic analysis of adjuvant interferon alfa-2b in high-risk melanoma based on projections from Eastern Cooperative Oncology Group 1684

PURPOSE

Interferon alfa-2b (IFN) in a randomized clinical trial (E1684) prolonged relapse-free and total survival in high-risk resected melanoma. However, the costs and toxicities of IFN are barriers to its widespread use. This study was undertaken to analyze the projected costs and long-term benefits of IFN by combining prospectively collected data on IFN actual dosage, time of recurrence, and survival with secondary data on long-term melanoma recurrence risks to project the cost-effectiveness of adjuvant IFN compared with observation.

PATIENTS AND METHODS

Two hypothetical cohorts of 50-year-old melanoma patients whose mean IFN dosage and clinical results were directly taken from E1684 were included in the study. Melanoma recurrence risks beyond 5 years were derived from international databases. Melanoma recurrence care costs and quality-of-life adjustments, when considered, were based on expert consensus. End points were incremental costs, life-years gained, and cost per life-year gained with and without quality-of-life adjustments.

RESULTS

The IFN cohort was projected to have an increased (undiscounted) survival of 0.52 years at 7 years and 1.90 years over a lifetime. The projected incremental cost (in 1996 United States dollars) per life-year gained in the IFN cohort ranged from $13,700 after 35 years to $32,600 at 7 years, the median follow-up of E1684. Using assigned quality-of-life values for IFN and recurrence, the lifetime cost per quality adjusted life-year increased to $15,200. Even if treatment costs for recurrence were excluded, the lifetime incremental cost per life-year gained was $21,600.

CONCLUSION

The cost and toxicity of IFN must be balanced against its projected benefits in high-risk melanoma. The derived cost-effectiveness and cost-utility ratios for IFN were comparable to other cancer interventions for which cost-effectiveness analysis has been performed.

High-dose chemotherapy with autologous hematopoietic stem-cell support for breast cancer in North America

PURPOSE

To identify trends in high-dose therapy with autologous hematopoietic stem-cell support (autotransplants) for breast cancer (1989 to 1995).

PATIENTS AND METHODS

Analysis of patients who received autotransplants and were reported to the Autologous Blood and Marrow Transplant Registry. Between January 1, 1989 and June 30, 1995, 19,291 autotransplants were reviewed; 5,886 were for breast cancer. Main outcomes were progression-free survival (PFS) and survival.

RESULTS

Between 1989 and 1995, autotransplants for breast cancer increased sixfold. After 1992, breast cancer was the most common indication for autotransplant. Significant trends included increasing use for locally advanced rather than metastatic disease (P < .00001) and use of blood-derived rather than marrow-derived stem cells (P < .00001). One-hundred-day mortality decreased from 22% to 5% (P < .0001). Three-year PFS probabilities were 65% (95% confidence intervals [Cls], 59 to 71) for stage 2 disease, and 60% (95% Cl, 53 to 67) for stage 3 disease. In metastatic breast cancer, 3-year probabilities of PFS were 7% (95% Cl, 4 to 10) for women with no response to conventional dose chemotherapy; 13% (95% Cl, 9 to 17) for those with partial response; and 32% (95% Cl, 27 to 37) for those with complete response. Eleven percent of women with stage 2/3 disease and less than 1% of those with stage 4 disease participated in national cooperative group randomized trials.

CONCLUSION

Autotransplants increasingly are used to treat breast cancer. One-hundred-day mortality has decreased substantially. Three-year survival is better in women with earlier stage disease and in those who respond to pretransplant chemotherapy.

Measuring standards of care for early breast cancer in an insured population

PURPOSE

To demonstrate the use of a combined data base to evaluate the care for local/regional invasive breast cancer in a large insured population of women aged less than 64 years.

PATIENTS AND METHODS

We linked the procedural and hospital claims from Blue Cross Blue Shield (BCBS) of Virginia with clinical stage data from the Virginia Cancer Registry (VCR) from 1989 to 1991. A total of 918 women were assessed with a median age of 50 years; 68% had tumors less than 2 cm, 30% had positive axillary nodes, and 68% were assessed as having local summary stage. A quality-of-care "report card" was used based on standards of care from international Consensus Conferences.

RESULTS

Eight percent had a mastectomy as the initial biopsy procedure. Sixty-nine percent of women ultimately underwent mastectomy. Of those women who underwent lumpectomy, 86% had subsequent radiation. Within 3 months of diagnosis, 43% had a bone scan and 20% a computed tomography (CT) scan. Of women with positive axillary lymph nodes, 83% aged less than 51 years and 52% aged 51 to 64 years received chemotherapy. Fifty-six percent of all women had claims from a medical oncologist. Of women having a total mastectomy, 27% had claims from a plastic surgeon. Sixty-six percent to 76% of women had a mammogram, 24% a bone scan, and 14% a CT scan in the 0-18 and 18-36 month intervals following primary treatment.

CONCLUSION

This study confirms the feasibility of linking sources of data that provide complementary information needed to develop measurements regarding standards of quality and efficiency of oncologic care. This report should serve as an initial benchmark while we await reports from other populations to define the best practice.

Economic analysis of a randomized clinical trial to compare filgrastim-mobilized peripheral-blood progenitor-cell transplantation and autologous bone marrow transplantation in patients with Hodgkin's and non-Hodgkin's lymphoma

PURPOSE

High-dose chemotherapy (HDC) with peripheral-blood progenitor cell (PBPC) and autologous bone marrow (ABM) transplant (T) has documented survival benefits for relapsed Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). Treatment costs associated with HDC and its supportive care have restricted its use both on and off clinical trial. In a prospective randomized clinical trial, filgrastim-mobilized PBPCT resulted in faster recovery of bone marrow function, with less hospitalization and supportive care than ABMT. This study was undertaken to analyze the costs of the two strategies using prospectively collected data from a randomized clinical trial that compared filgrastim-mobilized PBPCT versus ABMT.

PATIENTS AND METHODS

Clinical results and resource utilization from a randomized clinical trial that compared filgrastim-mobilized PBPCT versus ABMT following carmustine, etoposide, cytarabine, and melphalan (BEAM) HDC for HD and NHL are presented. The trial was performed in six centers in Germany, the United Kingdom, and Belgium. Resource utilization data were used to project costs and Massay Cancer Center (MCC) in the United States incurred the cost of treating the cohort. Costs were projected to the United States, because the economic implications to United States centers are significant, costs of care vary markedly among countries but resource utilization on this trial did not, and a randomized trial is unlikely to be performed in the United States.

RESULTS

Fifty-eight patients with relapsed HD or NHL underwent HDC with BEAM. The PBPCT and ABMT groups had similar short-term survival after BEAM. PBPCT patients had a shorter hospitalization (median, 17 v 23 days; P = .002), neutrophil recovery (11 v 14 days; P = .005), platelet recovery to > or = 20 x 10(9)/L (16 v 23 days; P = .02), and days of platelet transfusions (6 v 10; P < .001). Estimated costs were $8,531 for ABM harvest and $5,760 for PBPC collection, including filgrastim mobilization. The total estimated average cost was $59,314 for each ABMT patient versus $45,792 for each PBPCT patient. Cost savings of $13,521 (23%) were due to shorter hospitalizations with less supportive care.

CONCLUSION

PBPCT is as safe and more effective than ABMT for HD and NHL in the short term. PBPCT represents a significant cost savings due to lower autograft collection costs, shorter hospital stays, and less supportive care. The savings exceed the costs for filgrastim mobilization and PBPC collection. Actual savings will vary depending on local practice patterns, charges, and costs.

Use of hematopoietic colony-stimulating factors: the American Society of Clinical Oncology survey. The Health Services Research Committee of the American Society of Clinical Oncology

PURPOSE

Dissemination of use of the hematopoietic colony-stimulating factors (CSFs) is unprecedented in oncology, with almost all physicians having experience with granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) shortly after the drugs received Food and Drug Administration (FDA) approval in 1991. The American Society of Clinical Oncology (ASCO) Health Services Research Committee sought to assess patterns of use of CSFs before dissemination of its first-ever publication of ASCO guidelines.

METHODS

A questionnaire describing clinical scenarios was mailed to American oncologists and hematologists who practice medical oncology. In each scenario, the physician was asked whether he would prefer to use a CSF to prevent or treat neutropenia.

RESULTS

The response rate to the mailed survey was 49% (N = 475). Most physicians preferred to use CSFs for secondary prophylaxis in patients receiving chemotherapy at rates of 44% to 85%, rather than reduce doses. Patterns of use did not differ for palliative, curative, or adjuvant chemotherapy. While the majority of CSF patterns of care were similar to those recommended in the ASCO guidelines, more than half of the physicians chose to use CSFs in the treatment of febrile neutropenia, an area not supported in the subsequent guidelines. In general, physicians at academic medical centers and in Health Maintenance Organization (HMO) practices were more likely to prefer dose-reduction strategies over addition of CSFs, while fee-for-service physicians preferred the opposite strategies.

CONCLUSION

Variations in CSF preferences for use were related to differences in clinical characteristics (history of afebrile v febrile neutropenia), drug characteristics (G-CSF or GM-CSF), and physician practice characteristics (HMO or fee-for-service setting). However, before dissemination of the guidelines, the majority of American oncologists preferred strategies that were subsequently included in the ASCO CSF guidelines. CSF guidelines would be most likely to reduce CSF use for treatment of afebrile and uncomplicated febrile neutropenia.

Cost-effective models for flutamide for prostate carcinoma patients: are they helpful to policy makers?

BACKGROUND

More than 50,000 male patients received hormonal therapy for metastatic prostate carcinoma in 1995. Nonsteroidal antiandrogens, such as flutamide, when used in conjunction with castration, are effective in prolonging the time to progression of disease and survival. Only one-third of newly diagnosed patients with metastatic prostate carcinoma receive flutamide. Physicians may be reluctant to prescribe flutamide because of quality of life, toxicity, and cost considerations.

METHODS

Physician focus groups evaluated quality of life factors for metastatic prostate cancer.

RESULTS

Using quality of life estimates with the National Cancer Institute's (NCI) 0036 clinical trial results, our revised model of flutamide use predicted that, for minimal disease, survival increased by 4.33 quality adjusted months (QAMs) at an incremental cost of $25,000 per quality adjusted life year (QALY) saved and for severe disease, survival increased by 4.11 QAM at a cost of $18,000 per QALY saved. However, if quality of life estimates are used in conjunction with the Prostate Cancer Trialists' Collaborative Group (PCTCG) meta-analysis estimates, survival increased by 2.1 QAM at an incremental cost of $41,000 per QALY saved for persons with severe disease and increased by 2.6 QAM at an incremental cost of $53,700 per QALY saved for persons with minimal disease.

CONCLUSIONS

Using NCI 0036 trial data, flutamide has an incremental cost-effectiveness more favorable than most therapies, while estimates based on the PCTCG found a less favorable outcome for the drug. Concerns about out-of-pocket expenditures and efficacy limit flutamide utilization; quality of life considerations are less cogent.

Estimating the cost-effectiveness of stereotaxic biopsy for nonpalpable breast abnormalities: a decision analysis model

RATIONALE AND OBJECTIVES

We examined the clinical and economic trade-offs of shifting from surgical excisional biopsy to stereotaxic core breast biopsy for evaluating non-palpable, mammographically detected breast lesions.

METHODS

A decision analysis model compared strategies beginning with excisional or stereotaxic core biopsy for hypothetical cohorts of 1,000 women. All women with negative initial biopsies had a 6-month follow-up mammogram. Sensitivities and specificities were based on the literature and expert estimates. Pretest probabilities of invasive cancer and in situ cancer were each 10% based on mammographic features. Adjusted costs were based on an audit of patients evaluated at the Medical College of Virginia and physician relative value units.

RESULTS

Per 1,000 women, with an expected rate of 100 invasive and 100 in situ cancers, the stereotaxic core biopsy strategy would initially miss 6.7 invasive and 12.4 in situ cases. Most of these would be detected at 6-month follow-ups. Of the women having a stereotaxic core biopsy, 75.7% avoided a surgical procedure. Using stereotaxic core biopsy saved $804 per woman. Continuing to initially use surgical biopsy, total management costs were an additional $42,100 per each case of early detected invasive or in situ cancer. A speculative sensitivity analysis, in which the prognosis of invasive cancer was worse if diagnosis was delayed by 6 months, indicated that surgical biopsy had an incremental cost of $156,700 per additional life year gained.

CONCLUSION

Using conservative estimates for the false-negative rate of stereotaxic core breast biopsy, widespread use of stereotaxic biopsy is projected to have substantial cost savings with a slight compromise in the rate of early detection. Whether the decremental cost-effectiveness is acceptable is dependent on the natural history of cancers whose diagnosis is delayed.

Cost-effectiveness analysis of three regimens using vinorelbine (Navelbine) for non-small cell lung cancer

The costs and cost-effectiveness of different treatments are increasing concerns in healthcare. Vinorelbine (Navelbine; Burroughs Wellcome Co, Research Triangle Park, NC; Pierre Fabre Medicament, Paris, France), the first new agent approved for the treatment of metastatic non-small cell lung cancer (NSCLC) in more than a decade, was recently approved in the United States. In this report the terminology of cost-effectiveness analysis is reviewed and the findings from a comparative cost-effectiveness analysis of three regimens for NSCLC are discussed. The findings are from a randomized clinical trial of vinorelbine alone versus vinorelbine plus cisplatin versus vindesine plus cisplatin in 612 European patients with NSCLC (J Clin Oncol 12:360-367, 1994) and from cost data from the Medical College of Virginia. In this study the vinorelbine plus cisplatin regimen was the most effective, with a mean survival of 49.6 weeks. Using vinorelbine alone as the baseline, vinorelbine plus cisplatin added 56 days of life at an additional cost of $2,700, resulting in an incremental cost-effectiveness ratio of $17,700 per year of life gained. Similarly, vindesine plus cisplatin added 19 days of life at a cost of $1,150, or $22,100 per year of life gained. Compared with vindesine plus cisplatin, vinorelbine plus cisplatin added 37 days of life at a cost of $1,570, or $15,500 per year of life gained. The cost-effectiveness of the vinorelbine plus cisplatin regimen was within the accepted limits for medical interventions. If vinorelbine is preferred because of its more favorable toxicity profile, adding cisplatin to the treatment regimen substantially increases efficacy at an acceptable cost. The study demonstrated that, compared with other available medical interventions, chemotherapy for NSCLC has acceptable efficacy and cost effectiveness. Access to treatment should not be denied on the basis of clinical or economic grounds.

Economic considerations in the care of lung cancer patients

Lung cancer has been characterized as an expensive, futile, and self-induced illness. One of the most common questions pertaining to treatment is, "Is it worth it?" In the era of health care reform, attention has been directed toward common, high-cost illnesses that may benefit from closer examination of the clinical decisions that drive costs. This review explores the economic considerations of lung cancer treatment from the perspective of the patient, society, and those at risk for the costs of care. The concept of value is proposed as a frame-work to guide how lung cancer treatments should and should not be routinely used. Cost-effectiveness studies are highlighted that do not paint as dim a view of lung cancer therapy as may have been thought. However, it is clear that the 10 billion dollars spent yearly on lung cancer might be better used by limiting expenditures to the aspects of care that produce the best outcomes. This review includes comparisons of the cost-effectiveness of lung cancer care and treatments for other common cancers. It concludes with some strategies to use resources allocated to lung cancer more effectively.

Factors that determine the treatment for local and regional prostate cancer

This article assesses the significance of comorbid and nonclinical factors in type of treatment received by elderly male patients with local-regional stage prostate cancer. Multivariate analysis of data from the Virginia Cancer Registry was linked to Medicare claim files, the Area Resource File, and 1990 Census Data. The type of initial treatment received was studied in 3117 men with local-regional staged prostate cancer diagnosed from 1985 to 1989. The frequency of surgical and radiation therapy for prostate cancer rose between 1985 and 1989 (12.5% to 18.5% for surgery, P < 0.001; 25% to 32% for radiation, P < 0.001). Age was the most important predictor of therapeutic choice; no therapy was given to 26% of men 65 to 69 years old versus 63% of men 85 years or older P < 0.001). Race, residence (rural versus urban), and comorbidity were also strong factors in predicting initial therapy. Using logistic regression, three treatment alternatives were evaluated. Age (odds ratio [OR] .51; 99% confidence interval [CI] = .43, .60), comorbidity (OR .72; 99% CI .63, .82), income (OR 1.14; 99% CI 1.01, 1.28), residence (OR .65; 99% CI .48, .87), diagnosis year (OR 1.15; 99% CI 1.07, 1.23) all were associated independently with treatment versus no treatment. For surgery versus radiation, age (OR .40; 99% CI .27, .57), race (OR 2.92; 99% CI 1.65, 5.15) and education (OR 1.75; 99% CI 1.31, 2.34) were significant factors. For hormonal/orchiectomy versus surgery/radiation, age (OR 5.19; 99% CI 3.84, 7.01), comorbidity (OR 1.28; 99% CI 1.03, 1.58), distance to radiation oncologist (OR .89; 99% CI .80, .99), and diagnosis year (OR .89; 99% CI .79, 1.00) were significant. The number of men receiving surgical and radiation treatments for prostate cancer increased between 1985 and 1989. During that period, age consistently played a significant role in all therapeutic decisions. Other factors, such as comorbidity, race, socioeconomic status, and distance, also were important considerations, depending on the treatment alternative.

Economic and cost-effectiveness issues in breast cancer treatment

The need for cost-effectiveness analyses is based on the unfortunate but universal situation of limited financial resources that ideally should be used to maximal benefit. Formal cost-effectiveness analyses assume a societal utilitarian perspective with the objective of maximizing net health benefit for members of a population within a limited level of resources. This societal perspective is in stark contrast to the clinician's perspective, whose goal is to maximize his or her patient's health status (no matter what effect those decisions have on other patients or resources). This difference in perspective and objectives explains why many clinicians object to the use of cost-effectiveness analysis in setting policies. When considering the natural history of breast cancer from screening, evaluation of suspicious lesions, primary therapy, staging, adjuvant therapy, monitoring, metastatic disease, and palliative care, it is striking that most cost-effectiveness studies have been related to screening or the use of adjuvant drug therapies. In prior work our group has shown that the use of chemotherapy in node-negative breast cancer and of tamoxifen alone or in combination with chemotherapy in premenopausal women are cost-effective compared with other common medical treatments. Given the increasing pressure to contain costs in contemporary medicine, one should remember that cost effectiveness is related to value, value defined as quality/costs. Examples are discussed when the controversy focuses on increasing quality (eg, valued outcomes, such as additional years of life or years of breast preservation) and on controlling costs (eg, integrating multidisciplinary care, minimizing superfluous testing, or reducing surgical biopsy rates). Efforts should be directed at both sides of this ratio.

Variation in staging and treatment of local and regional breast cancer in the elderly

BACKGROUND

Few studies of practice variation in the management of early breast cancer for elderly women have examined the process of care in depth. This study evaluated the effects of age and other factors on surgical staging techniques and treatment.

METHODS

Virginia cancer registry data were linked with Medicare claims and 1990 census data. The sample included all newly diagnosed patients with pathologic confirmed local and regional breast cancer in 1985-1989 (n = 3,361). Analyses included descriptive univariate statistics and multiple logistic regression analysis for staging and treatment alternatives. Process of care variables included tumor size determination, axillary lymph node dissection, use of adjuvant therapy, and radiation if breast conserving surgery (BCS) was performed.

RESULTS

About 75 percent of women had tumor size and axillary node dissection. Increasing comorbidity was associated with a lower likelihood of axillary node dissection. Nine percent of local compared to 44 percent of regional disease patients received adjuvant therapy. Hormonal therapy increased from 13 percent of women in 1985-1988 to 24 percent in 1989. Hormonal therapy did not vary with patient age. One-third of the patients with positive lymph nodes compared to 8 percent of node negative women received hormonal therapy. Blacks were more likely to present with advanced disease. A logistic regression model evaluated the multiple effects of patients and clinical characteristics: older women were more likely to present with larger tumors, were less likely to have axillary node dissections, and were less likely to receive chemotherapy or radiation.

CONCLUSIONS

Younger age was most consistently associated with staging and the use of chemotherapy in this cohort of elderly breast cancer patients. Based on the reported initial treatment plan, hormonal therapy was infrequently used and information from axillary lymph node assessment was used to stratify treatment. Although the low use of adjuvant hormonal therapy in elderly women may compromise survival, neither comorbid nor socioeconomic factors as measured in this study explained this practice pattern.

Role of decision analysis in relation to clinical trials and a US perspective of the Battelle model

Economic assessment of evolving technologies is assuming increasing importance worldwide. One form of economic assessment uses decision analysis, a simulation technique, to determine whether performing a clinical trial is worthwhile. This type of assessment may streamline data collection within a clinical trial, and can aid in the interpretation of a trial result with substantial benefits and toxicities. Although second-line chemotherapy for patients with metastatic breast cancer is in common use, its benefit is unclear and it is associated with substantial cost. A database search of currently active or recently closed randomised phase III comparative trials for metastatic breast cancer found only 6 trials involving a comparison of chemotherapies. Only 1 trial allowed prior chemotherapy for metastatic disease. Given the paucity of forthcoming clinical data, decision analysis is an appropriate tool for estimating the effectiveness of potential treatments with second-line agents for metastatic breast cancer. The findings of the Battelle decision analysis model, described in this issue, identified response rates and 1-year mortality as the key areas of focus for comparative trials. Decision analysis can improve the design and efficacy of prospective, comparative trials but cannot replace them.

Trade-offs between survival and breast preservation for three initial treatments of ductal carcinoma-in-situ of the breast

PURPOSE

To assess the trade-offs between survival and breast preservation of currently accepted approaches for ductal carcinoma-in-situ (DCIS) of the breast.

PATIENTS AND METHODS

Decision analysis was performed using the Markov model of hypothetical cohorts of 55-year-old white women with nonpalpable mammographic abnormalities found to be DCIS. Strategies were breast-conserving surgery (BCS), BCS with 50-Gy radiation (RT) or initial mastectomy. Recurrence rates were derived from the published literature. Main outcomes were overall, breast cancer-free, and event-free survival plus years of both breasts preserved.

RESULTS

Using the conditions defined in this model, the actuarial survival rates at 10 and 20 years were 91.7% and 74.1% for the initial mastectomy strategy, 91.0% and 72.1% for BCS plus RT, and 89.6% and 68.2% for BCS alone. At 20 years, the initial mastectomy strategy also had a greater breast cancer-free survival rate of 74.5%, compared with 63.3% for BCS plus RT, or 46.8% for BCS alone. However, BCS alone had the highest survival rate with both breasts preserved (64.2%) compared with BCS plus RT (56.0%) or initial mastectomy (0%). Of the breast-conserving strategies at 20 years, the breast event-free survival rate (no invasive cancer or DCIS) was greater for BCS plus RT (47.2%) compared with BCS alone (28.4%). Using just survival as the primary end point, mastectomy is the optimal strategy by a small margin. However, if quality-adjusted survival is at issue, mastectomy is the choice only if the yearly reduction in quality of life due to mastectomy is less than 1%.

CONCLUSION

BCS with or without radiation compared with mastectomy as initial management of DCIS of the breast trades a slight decrease in survival rates for the value of breast preservation. This model should aid clinicians in matching treatments to their patients' preferences.

Differences in initial treatment patterns and outcomes of lung cancer in the elderly

BACKGROUND

Non-small cell lung cancer (NSCLC) accounts for substantial deaths and costs in the elderly greater than 65 years old. The current practice of NSCLC treatment in a Medicare population was examined to ascertain important areas of practice variation, and differences in clinical outcome and costs.

METHODS

Data from incident cases of NSCLC from the Virginia Cancer Registry (VCR), 1985-89, were matched with claims from Medicare Part A and B, census tract data and the Area Resource File. Multivariate models were created to include clinical data, demographics, and access information.

RESULTS

For patients with locoregional disease, increasing age was associated with lower likelihood of therapy (odds ratio (OR) 0.35; confidence intervals (CI) 0.29, 0.43), thoracotomy (OR 0.27; CI 0.21, 0.34), and more use of radiation therapy compared to surgery (OR 1.69; CI 1.39, 2.03). Low education levels were associated with less likelihood of treatment (OR 0.78; CI 0.66, 0.94), or radiation instead of surgery (OR 1.22; CI 1.05, 1.47). Patients in urban areas were less likely to receive therapy (OR 0.67; CI 0.49, 0.92). For distant disease, increasing age was also associated with lower likelihood of treatment (OR 0.48; CI 0.41, 0.56), as was increasing co-morbidity (OR 0.84; CI 0.75, 0.93). Distance to radiation oncologists made no difference in radiotherapy utilization. Two year survival according to therapy was surgery 66%, radiation 15%, no therapy 17%.

CONCLUSIONS

Patterns of care, and survival according to therapy, vary widely for elderly NSCLC patients. Age, low education, higher co-morbidity and urban residence all decrease the likelihood of surgical therapy for locoregional NSCLC. Despite the availability of coverage through the Medicare program, use of therapies and survival is not uniform for all beneficiaries. Possible discrimination by age, co-morbid illnesses not recorded in the Medicare files, or patient and provider choice could all be involved; administrative billing files cannot resolve these important differences.