Cost-Effectiveness Modeling of Surgery Plus Adjuvant Endocrine Therapy Versus Primary Endocrine Therapy Alone in UK Women Aged 70 and Over With Early Breast Cancer.

OBJECTIVES: Approximately 20% of UK women aged 70+ with early breast cancer receive primary endocrine therapy (PET) instead of surgery. PET reduces surgical morbidity but with some survival decrement. To complement and utilize a treatment dependent prognostic model, we investigated the cost-effectiveness of surgery plus adjuvant therapies versus PET for women with varying health and fitness, identifying subgroups for which each treatment is cost-effective. METHODS: Survival outcomes from a statistical model, and published data on recurrence, were combined with data from a large, multicenter, prospective cohort study of over 3400 UK women aged 70+ with early breast cancer and median 52-month follow-up, to populate a probabilistic economic model. This model evaluated the cost-effectiveness of surgery plus adjuvant therapies relative to PET for 24 illustrative subgroups: Age {70, 80, 90} × Nodal status {FALSE (F), TRUE (T)} × Comorbidity score {0, 1, 2, 3+}. RESULTS: For a 70-year-old with no lymph node involvement and no comorbidities (70, F, 0), surgery plus adjuvant therapies was cheaper and more effective than PET. For other subgroups, surgery plus adjuvant therapies was more effective but more expensive. Surgery plus adjuvant therapies was not cost-effective for 4 of the 24 subgroups: (90, F, 2), (90, F, 3), (90, T, 2), (90, T, 3). CONCLUSION: From a UK perspective, surgery plus adjuvant therapies is clinically effective and cost-effective for most women aged 70+ with early breast cancer. Cost-effectiveness reduces with age and comorbidities, and for women over 90 with multiple comorbidities, there is little cost benefit and a negative impact on quality of life.

Opportunities and priorities for breast surgical research.

The 2013 Breast Cancer Campaign gap analysis established breast cancer research priorities without a specific focus on surgical research or the role of surgeons on breast cancer research. This Review aims to identify opportunities and priorities for research in breast surgery to complement the 2013 gap analysis. To identify these goals, research-active breast surgeons met and identified areas for breast surgery research that mapped to the patient pathway. Areas included diagnosis, neoadjuvant treatment, surgery, adjuvant therapy, and attention to special groups (eg, those receiving risk-reducing surgery). Section leads were identified based on research interests, with invited input from experts in specific areas, supported by consultation with members of the Association of Breast Surgery and Independent Cancer Patients' Voice groups. The document was iteratively modified until participants were satisfied that key priorities for surgical research were clear. Key research gaps included issues surrounding overdiagnosis and treatment; optimising treatment options and their selection for neoadjuvant therapies and subsequent surgery; reducing rates of re-operations for breast-conserving surgery; generating evidence for clinical effectiveness and cost-effectiveness of breast reconstruction, and mechanisms for assessing novel interventions; establishing optimal axillary management, especially post-neoadjuvant treatment; and defining and standardising indications for risk-reducing surgery. We propose strategies for resolving these knowledge gaps. Surgeons are ideally placed for a central role in breast cancer research and should foster a culture of engagement and participation in research to benefit patients and health-care systems. Development of infrastructure and surgical research capacity, together with appropriate allocation of research funding, is needed to successfully address the key clinical and translational research gaps that are highlighted in this Review within the next two decades.

Nation-Scale Adoption of Shorter Breast Radiation Therapy Schedules Can Increase Survival in Resource Constrained Economies: Results From a Markov Chain Analysis.

PURPOSE: Hypofractionated whole breast irradiation and accelerated partial breast irradiation (APBI) offer women options for shorter courses of breast radiation therapy. The impact of these shorter schedules on the breast cancer populations of emerging economies with limited radiation therapy resources is unknown. We hypothesized that adoption of these schedules would improve throughput in the system and, by allowing more women access to life-saving treatments, improve patient survival within the system. METHODS AND MATERIALS: We designed a Markov chain model to simulate the different health states that a postlumpectomy or postmastectomy patient could enter over the course of a 20-year follow-up period. Transition rates between health states were adapted from published data on recurrence rates. We used primary data from a tertiary care hospital in Lahore, Pakistan, to populate the model with proportional use of mastectomy versus breast conservation and to estimate the proportion of patients suitable for APBI. Sensitivity analyses on the use of APBI and relative efficacy of APBI were conducted to study the impact on the population. RESULTS: The shorter schedule resulted in more women alive and more women remaining without evidence of disease (NED) compared with the conventional schedule, with an absolute difference of about 4% and 7% at 15 years, respectively. Among women who had lumpectomies, the chance of remaining alive and with an intact breast was 62% in the hypofractionation model and 54% in the conventional fractionation model. CONCLUSIONS: Increasing throughput in the system can result in improved survival, improved chances of remaining without evidence of disease, and improved chances of remaining alive with a breast. These findings are significant and suggest that adoption of hypofractionation in emerging economies is not simply a question of efficiency and cost but one of access to care and patient survivorship.

Resident and Fellow Participation in Breast Surgery: An American College of Surgeons NSQIP Clinical Outcomes Analysis.

BACKGROUND: In our present health and medical education system, participation of residents and fellows is under increasing scrutiny regarding their role in surgery and the outcomes of the procedure. Our goal was to perform a clinical outcomes analysis investigating resident and fellow participation in breast surgery. STUDY DESIGN: Early postoperative complication rates and total operation times for partial and simple mastectomy cases were gathered from the ACS-NSQIP database. The cases were divided based on the training level of the participating resident surgeon: junior (post-graduate year [PGY] 1 to 2), senior (PGY 3 to 5), fellow (PGY > 5), as well as an attending only group (no resident present). We compared the clinical outcomes of each group with the attending only group. Statistical analysis included odds ratios and regression analysis that analyzed the correlation between years in training vs complication rate, and years in training vs total operation time. RESULTS: A total of 13,254 cases were identified, and residents participated in 64% of them. There was no statistically significant difference in rate of complications between any of the trainee groups when compared with the attending only group. However, total operative times were correlated with training year levels and found to be significantly lower with each year of training (R(2) = 0.53, p = 0.025 for partial mastectomy; R(2) = 0.45, p = 0.046 for complete mastectomy). CONCLUSIONS: Resident/fellow participation does not negatively affect early postoperative breast surgery outcomes, and complication rates are unrelated to the training level of the participating resident/fellow surgeon.

Survival in stage I-III breast cancer patients by surgical treatment in a publicly funded health care system.

BACKGROUND: Recent investigations of breast cancer survival in the United States suggest that patients who receive mastectomy have poorer survival than those who receive breast-conserving surgery (BCS) plus radiotherapy, despite clinically established equivalence. This study investigates breast cancer survival in the publicly funded health care system present in Alberta, Canada. PATIENTS AND METHODS: Surgically treated stage I-III breast cancer cases diagnosed in Alberta from 2002 to 2010 were included. Demographic, treatment and mortality information were collected from the Alberta Cancer Registry. Unadjusted overall and breast cancer-specific mortality was assessed using Kaplan-Meier and cumulative incidence curves, respectively. Cox proportional hazards models were used to calculate stage-specific mortality hazard estimates associated with surgical treatment received. RESULTS: A total of 14 939 cases of breast cancer (14 633 patients) were included in this study. The unadjusted 5-year all-cause survival probabilities for patients treated with BCS plus radiotherapy, mastectomy, and BCS alone were 94% (95% CI 93% to 95%), 83% (95% CI 82% to 84%) and 74% (95% CI 70% to 78%), respectively. Stage II and III patients who received mastectomy had a higher all-cause (stage II HR = 1.36, 95% CI 1.13-1.48; stage III HR = 1.74, 95% CI 1.24-2.45) and breast cancer-specific (stage II HR = 1.39, 95% CI 1.09-1.76; stage III HR = 1.79, 95% CI 1.21-2.65) mortality hazard compared with those who received BCS plus radiotherapy, adjusting for patient and clinical characteristics. BCS alone was consistently associated with poor survival. CONCLUSIONS: Stage II and III breast cancer patients diagnosed in Alberta, Canada, who received mastectomy had a significantly higher all-cause and breast cancer-specific mortality hazard compared with those who received BCS plus radiotherapy. We suggest greater efforts toward educating and encouraging patients to receive BCS plus radiotherapy rather than mastectomy when it is medically feasible and appropriate.

Prophylactic bilateral salpingo-oophorectomy (PBSO) with or without prophylactic bilateral mastectomy (PBM) or no intervention in BRCA1 mutation carriers: a cost-effectiveness analysis.

Women with germline BRCA1 mutation have a significant risk of breast and/or ovarian cancer. Prophylactic bilateral mastectomy (PBM) and prophylactic bilateral salpingo-oophorectomy (PBSO) prevent cancer in mutation carriers. The cost-effectiveness of PBSO (age of 35 years) with or without PBM five years earlier was compared to a no intervention setting employing a marginal cost analysis. National data on cancer incidence, mortality rates and costs were implemented together with observed Norwegian BRCA1 data in a Markov model and PBSO was assumed to reduce the risk of ovarian cancer by 90%. A 3% discount rate was used. The additional health care cost per mutation carrier undergoing PBSO and PBM was euro 15,784, and 6.4 discounted life years gained (LYG) was indicated (PBSO alone with 100% acceptance 3.1 LYG). The additional cost per LYG was euro 1973 (PBSO alone euro 1749/LYG). Including all resource use, the figure was a cost of euro 496 and euro 1284 per LYG, respectively. PBSO with or without PBM in BRCA1 mutation carriers is cost-effective. A testing of all incident breast cancers to identify mutation carrying families should be explored.

Breast conservation therapy rates are no different in medically indigent versus insured patients with early stage breast cancer.

PURPOSE: Multiple prospective, randomized studies show that breast conservation therapy (BCT) results in survival rates equal to mastectomy (Mx) for patients with early stage breast cancer (ESBC). Nevertheless, BCT remains underused in certain areas of the nation, without clearly definable reasons. Several studies have implicated socioeconomic status as one potential cause for this disparity in BCT usage. We sought to compare BCT rates in the medically indigent versus insured patients, within the same institution. METHODS: Data from 1993 to 2000, collected from the institutional tumor registry and the hospital's claims records, were analyzed for 928 patients with ESBC (Stages 0, I, and II), treated at a single medical center. The same surgeons treated both insured and indigent patients. Patients treated by BCT or Mx were compared for age, race, stage, insurance status, access to a radiation therapy center, surgeon, and year of diagnosis. RESULTS: Patient age, race, surgeon, or insurance status did not significantly affect the rate of mastectomy. Stage I patients (P < 0.001) and those treated after 1995 had higher BCT rates (54.9% in 1993-95 vs. 70.7% in 1996-2000; P < 0.001). Travel distance to a radiation therapy center had no significant impact on BCT rates, except for patients >40 miles distant. CONCLUSIONS: These data refute the hypothesis that socioeconomic status, as reflected by medical insurance, is a determinant of BCT in women with ESBC. Distance of <40 miles to a radiation therapy facility, Stage I disease, and diagnosis after 1995 were factors associated with higher BCT rates.

Breast-conserving treatment or mastectomy in early breast cancer: a clinical decision analysis with special reference to the risk of local recurrence.

A clinical decision analysis was performed to judge the impact of local recurrences after breast-conserving treatment (BCT) on the (quality-adjusted) life expectancy of breast cancer patients. A life-long follow-up of two patient groups, one of which had undergone mastectomy and one BCT, was simulated by a Markov model of medical prognosis. Data used in the model originated from the literature. Since results in the source papers were not split according to stage, we performed two analyses: one with data from all source studies (T1 and T2) and one with data from source studies, concerning only T1 patients. In both analyses, the conclusion was that BCT yields better quality-adjusted life expectancy than mastectomy. Sensitivity analysis, however, identified subgroups of patients who should preferably undergo mastectomy. These subgroups are: patients preferring mastectomy to BCT, patients with a high risk of local recurrence, young patients and patients at high age, if they also have a high local recurrence risk. For these groups, patient preferences should play a major role in recommending treatment.

[Assessment of the prognostic value of clinico-morphologic factors in breast cancer using a computer]. / Otsenka prognosticheskoi znachimosti nekotorykh kliniko-morfologicheskikh faktorov pri rake molochnoi s pomoshch'iu EVM.

Under study was the possibility to prognostigate the late results of radical treatment of breast cancer patients based on the analysis of a sum of clinico-morphological findings, obtained by a routine clinical examination of patients. The analysis of various combinations of the factors made on an electronic computer has evidenced that the presence or absence of metastases in regional lymph nodes is of decisive importance for prognosticating. Other factors being taken into account do not contribute essentially to the precise prognosis. Poor prognosis is made for cases with multiple regional metastases, favourable--in patients without metastases, uncertain--in patient with single metastases.