RESUMEN
BACKGROUND: Reducing the rate of margin positivity and reoperations remains a paramount goal in breast-conserving surgery (BCS). This study assesses the effectiveness of standard partial mastectomy with cavity shave margins (CSM) compared with partial mastectomy with selective margin resection (SPM), with regard to outcomes of the initial surgeries, re-excisions, and overall costs. PATIENTS AND METHODS: This is a retrospective review of 122 eligible breast cancer patients who underwent BCS at one institution. The CSM and SPM groups each included 61 patients, matched for presurgical diagnoses and clinical stage. Data including margin status, rates and reason for re-excision, associated operation times, and costs were analyzed. RESULTS: Patients undergoing CSM had less than half the rate of positive margins (PMs) (10% vs. 23%; P = .03) and re-excisions (8% vs. 23%; P = .02) compared with SPM. In the former group, the margin involvement was focal, and re-excisions were performed almost exclusively for PMs. For SPM, the majority (92%) of PMs were on the main lumpectomy specimen rather than the selective margins, and re-excisions included, in addition to PMs, extensive or multifocal negative but close margins. Reduced breast tissue volumes were removed with CSM, particularly for patients undergoing a single surgery (47 vs. 165 cm3; P < .001). The initial surgery with CSM is on average 27% more costly than that for SPM (P < .001), due to the increased pathology costs which are partially offset by the increased re-excision rates in SPM. CONCLUSION: Circumferential cavity shaving, associated with consistent lower PMs, tissue volumes excised, and re-excision rates, is appropriate for routine implementation as a method offering superior surgical outcomes.
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Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/cirugía , Mastectomía Segmentaria/economía , Reoperación/economía , Anciano , Neoplasias de la Mama/economía , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/patología , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios RetrospectivosRESUMEN
BACKGROUND: Both breast-conserving surgery and breast reconstruction surgery are less popular in China, although they can improve patients' quality of life. The main reason comes from the economy. There is currently no economic evaluation of different surgical treatment options for early breast cancer. Our study aims to assess the economic impact and long-term cost-effectiveness of different surgical treatments for early breast cancer. The surgical approaches are including mastectomy (MAST), breast-conserving therapy (BCT), and mastectomy with reconstruction (MAST+RECON). METHODS: Based on demographic data, disease-related information and other treatments, we applied propensity score matching (PSM) to perform 1: 1 matching among patients who underwent these three types of surgery in the tertiary academic medical center from 2011 to 2017 to obtain a balanced sample of covariates between groups. A Markov model was established. Clinical data and cost data were obtained from the medical records. Health utility values were derived from clinical investigations. Strategies were compared using an incremental cost-effectiveness ratio (ICER). RESULTS: After PSM, there were 205 cases in each group. In the matched data set, the distribution of covariates was fully balanced. The total cost of MAST, MAST+RECON and BCT was $37,392.84, $70,556.03 and $82,330.97, respectively. The quality-adjusted life year (QALYs) were 17.11, 18.40 and 20.20, respectively. Compared with MAST, MAST+RECON and BCT have an ICER of $25,707.90/QALY and $14,543.08/QALY, respectively. The ICER of BCT vs. MAST was less than the threshold of $27,931.04. The reliability and stability of the results were confirmed by Monte Carlo simulation and sensitivity analysis. CONCLUSIONS: We believe that in the context of the limited resources in China, after comparing the three surgical approaches, BCT is the more cost-effective and preferred solution.
Asunto(s)
Neoplasias de la Mama/economía , Carcinoma Ductal de Mama/economía , Carcinoma Lobular/economía , Análisis Costo-Beneficio , Mastectomía Segmentaria/economía , Mastectomía/economía , Recurrencia Local de Neoplasia/economía , Adulto , Neoplasias de la Mama/patología , Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/patología , Carcinoma Ductal de Mama/cirugía , Carcinoma Lobular/patología , Carcinoma Lobular/cirugía , Estudios de Casos y Controles , China , Femenino , Estudios de Seguimiento , Humanos , Metástasis Linfática , Mastectomía/métodos , Mastectomía Segmentaria/métodos , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Pronóstico , Estudios Prospectivos , Calidad de Vida , Receptor ErbB-2/metabolismo , Receptores de Estrógenos/metabolismo , Receptores de Progesterona/metabolismo , Estudios RetrospectivosRESUMEN
BACKGROUND: There has been no comprehensive study determining the financial burden of breast cancer in the South African (SA) public sector. OBJECTIVES: To develop a method to determine the cost of breast cancer treatment with chemotherapy per episode of care and to quantify the associated costs relating to chemotherapy at Groote Schuur Hospital (GSH), a government hospital in SA. These costs included costs associated with the management of adverse events arising from chemotherapy. METHODS: Retrospective patient-level data were collected for 200 patients from electronic databases and patient folders between 2013 and 2015. Direct medical costs were determined from the health funder's perspective. The information collected was categorised into the following cost components: chemotherapy medicines, support medicines, administration of chemotherapy, laboratory tests, radiology scans and imaging, doctor consultations and adverse events. Time-and-motion studies were conducted on a set of new patients and the data obtained were used for the study sample of 200 patients. All the above costs were used to determine the cost of chemotherapy per episode of care. The episode of care was defined as the care provided from 2 months prior to the date of commencing chemotherapy (pre-chemotherapy phase), during chemotherapy (treatment phase) and until 6 months after the date when the last cycle of chemotherapy was administered (follow-up phase). RESULTS: A method was developed to determine the episode-of-care costs for breast cancer at GSH. The total direct medical cost for treatment of breast cancer at GSH for 200 patients was ZAR3 154 877, and the average episode-of-care cost per patient was ZAR15 774. The average cost of management of adverse events arising from the various treatment modalities was ZAR13 133 per patient. It was found that the cost of treating a patient with adverse events was 1.8 times higher than the cost of treating a patient without adverse events. Of the patients, 86.5% managed to complete their prescribed chemotherapy treatment cycles, and the average cost of treatment of these patients was 1.3 times more than the average cost for patients who could not complete their treatment, based on the number of treatment cycles received. CONCLUSION: A comprehensive method to determine the costs associated with breast cancer management per episode of care was developed, and costs were quantified at GSH according to the treatment protocol used at the hospital.
Asunto(s)
Antineoplásicos/economía , Carcinoma de Mama in situ/tratamiento farmacológico , Neoplasias de la Mama/tratamiento farmacológico , Carcinoma Ductal de Mama/tratamiento farmacológico , Carcinoma Lobular/tratamiento farmacológico , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/economía , Costos de la Atención en Salud/estadística & datos numéricos , Hospitales Públicos/economía , Adulto , Anciano , Carcinoma de Mama in situ/economía , Carcinoma de Mama in situ/patología , Neoplasias de la Mama/economía , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/patología , Carcinoma Lobular/economía , Carcinoma Lobular/patología , Quimioterapia Adyuvante/economía , Técnicas de Laboratorio Clínico/economía , Diagnóstico por Imagen/economía , Costos de los Medicamentos/estadística & datos numéricos , Episodio de Atención , Femenino , Humanos , Persona de Mediana Edad , Terapia Neoadyuvante/economía , Cuidados Paliativos/economía , Honorarios por Prescripción de Medicamentos/estadística & datos numéricos , Derivación y Consulta/economía , Estudios Retrospectivos , Sudáfrica , Estudios de Tiempo y Movimiento , Adulto JovenRESUMEN
PURPOSE: This retrospective study of community oncology patients with breast cancer gene (BRCA)-mutated metastatic breast cancer (MBC) examined treatment outcomes and health resource utilization (HRU) and costs for a sample of patients with human epidermal growth factor receptor 2 (HER2)-negative disease who were either hormone receptor positive (HR+) or triple negative breast cancer (TNBC). METHODS: Evidence from the Vector Oncology Data Warehouse, a repository of electronic medical records/billing data and provider notes, was analyzed. Treatment outcomes were progression-free survival (PFS) and overall survival (OS) from start of first-line therapy in the metastatic setting. HRU and cost measures were collected from the time of MBC diagnosis to end of the record. HRU included hospitalizations, emergency room visits, infused/parenteral supportive care drugs, and outpatient visits. Costs were computed both as total and monthly costs. RESULTS: 57 HR+ and 57 TNBC patients (2013-2015) met inclusion criteria. Eight TNBC patients did not get treatment. HR+ patients had median first line PFS of 12.1 months and TNBC patients had 6.1 months. HR+ patients had median OS from start of first line of 38.4 months, and TNBC patients had 23.4 months. Rate of use of infused/parenteral supportive care drugs was 25.5% overall and 36.7% among TNBC patients with 15.8% among HR+ patients. CONCLUSION: There is an unmet need in BRCA-mutated patients with MBC, including those with HR+ and TNBC disease. The unmet need among TNBC patients was most evident in that 12% were not treated and TNBC patients appeared to have poor treatment outcomes. MICRO ABSTRACT: Reviewed medical records for outcomes, resource utilization, and costs in 114 community patients with BRCA mutated metastatic breast cancer. 57 hormone positive (HP); 57 triple negative (TN). RESULTS: median PFS: 12.1 months HP; 6.1 TN. HP OS was 38.4; TN 23.4. Rate of infused supportive care drugs: 25.5% HP; 36.7% TN. Patients with TN disease need better therapeutic options.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/economía , Proteína BRCA1/genética , Proteína BRCA2/genética , Neoplasias de la Mama/tratamiento farmacológico , Costos y Análisis de Costo , Asignación de Recursos para la Atención de Salud/estadística & datos numéricos , Mutación , Adulto , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Biomarcadores de Tumor/genética , Neoplasias de la Mama/economía , Neoplasias de la Mama/genética , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/tratamiento farmacológico , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/genética , Carcinoma Ductal de Mama/secundario , Carcinoma Lobular/tratamiento farmacológico , Carcinoma Lobular/economía , Carcinoma Lobular/genética , Carcinoma Lobular/secundario , Centros Comunitarios de Salud , Femenino , Estudios de Seguimiento , Asignación de Recursos para la Atención de Salud/economía , Humanos , Neoplasias Inflamatorias de la Mama/tratamiento farmacológico , Neoplasias Inflamatorias de la Mama/economía , Neoplasias Inflamatorias de la Mama/genética , Neoplasias Inflamatorias de la Mama/secundario , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Re-excision rates after breast conservation surgery are reported to be 20%-40%. Inaccuracies with specimen orientation may affect margin assessment. This study examined whether the addition of surgeon performed intraoperative inking of the lumpectomy specimen after adoption of margin guidelines would be cost-effective. METHODS: A retrospective review of a prospective surgical database was performed from 2009 to 2017. Patients with initial lumpectomy and a preoperative diagnosis of invasive breast carcinoma or ductal carcinoma in situ (DCIS) were included. Re-excision rates and the surgical costs per 100 initial lumpectomies were compared across three periods: before margin guideline publication, after guideline adoption, and after the addition of intraoperative surgeon performed specimen inking. RESULTS: Four hundred initial lumpectomies were evaluated. Overall re-excision rate was 21% (n = 84). There was a nonsignificant reduction in re-excision rates after margin guidelines from 24% (n = 36) to 20% (n = 23) and to 19% (n = 25) after addition of intraoperative specimen ink. Re-excision rates were significantly lower for invasive cancer than for DCIS across three periods (20%, 15%, and 12% versus 37%, 33%, and 31%) (odds ratio 3.31, P = 0.007). The estimated cost of re-excision per 100 initial lumpectomies decreased after guidelines by 25% ($128,270) for invasive breast cancer and by 11% ($102,616) for DCIS. The addition of intraoperative specimen inking after margin guideline adoption resulted in further 17% cost savings ($66,692) for invasive breast cancer and 5% ($41,308) for DCIS. CONCLUSIONS: Surgeon performed intraoperative inking of the lumpectomy specimen after adoption of margin guidelines is a cost-effective technique in breast conservation surgery.
Asunto(s)
Neoplasias de la Mama/cirugía , Análisis Costo-Beneficio , Cuidados Intraoperatorios/economía , Márgenes de Escisión , Mastectomía Segmentaria/economía , Coloración y Etiquetado/economía , Cirujanos/economía , Neoplasias de la Mama/economía , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/cirugía , Carcinoma Intraductal no Infiltrante/economía , Carcinoma Intraductal no Infiltrante/cirugía , Ahorro de Costo/estadística & datos numéricos , Femenino , Florida , Humanos , Cuidados Intraoperatorios/métodos , Guías de Práctica Clínica como Asunto , Reoperación/economía , Reoperación/estadística & datos numéricos , Estudios RetrospectivosRESUMEN
OBJECTIVES: Industry-supported decision impact studies demonstrate that Oncotype Dx (ODX) changes treatment recommendations (TR) in 24-40% of hormone receptor+/HER2- patients. ODX is not reimbursed by third-party payers in Australia, potentially resulting in more selective use. We sought to evaluate the impact of self-funded ODX on TRs. METHODS: Data collected included demographics, tumor characteristics, indication for ODX and pre- and post-recurrence score (RS) TR. Primary endpoint was frequency of TR change and associations with TR change were sought. RESULTS: Eighteen physicians contributed 382 patients (median age 54). A total of 232 (61%) of tumors were T1 and were grade 1, 2 and 3 in 49 (13%), 252 (66%) and 79 (21%). A total of 257 (67%) were node negative. Assay indications were: confirm need for chemotherapy (CT) (36%), confirm omission of CT (40%) and genuine equipoise (24%). RS was low (≤17) in 55%, intermediate (18-31) in 36% and high (≥32) in 9%. Thirty-eight percent of patients had TR change post-ODX. Sixty-five percent of patients recommended CT pre-ODX changed to hormone therapy alone (HT)-more likely if lower grade and if ER and/or PR > 10%. Fourteen percent of patients with pre-ODX TR for HT added CT-more likely if ER and/or PR ≤10% and if Ki67 > 15% Overall, TR for CT decreased from 47% to 24%. CONCLUSION: Patient-funded ODX changed TRs in 38% of patients, de-escalating 65% from CT to HT and adding CT to 14% of those recommended HT. These changes were greater than an industry-funded study suggesting that physicians can identify situations where the assay may influence decisions.
Asunto(s)
Neoplasias de la Mama/tratamiento farmacológico , Carcinoma Ductal de Mama/tratamiento farmacológico , Carcinoma Lobular/tratamiento farmacológico , Toma de Decisiones , Perfilación de la Expresión Génica/economía , Pautas de la Práctica en Medicina/normas , Australia , Neoplasias de la Mama/economía , Neoplasias de la Mama/genética , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/genética , Carcinoma Lobular/economía , Carcinoma Lobular/genética , Quimioterapia Adyuvante , Femenino , Perfilación de la Expresión Génica/métodos , Humanos , Persona de Mediana Edad , PronósticoRESUMEN
BACKGROUND: The aim of this study was to estimate the total economic and health related burden of breast cancer in the Netherlands. METHODS: Data on incidence, prevalence, mortality and survival were extracted from the Dutch National Cancer Registry and were used to calculate the economic and health related burden of breast cancer for overall, DCIS (stage 0), early- (stage I), locally advanced- (stage II-III) and metastatic- (stage IV) breast cancer by age groups and by year (if applicable). RESULTS: The overall incidence of breast cancer increased from 103.4 up to 153.2 per 100,000 women between 1990 and 2014. The increase was driven by DCIS and early breast cancer as the incidence of locally advanced and metastatic breast cancer remained stable. Between 1990 and 2014, ten-year overall survival rates increased from 87% to 93% for early breast cancer, 41% to 62% for locally advanced- and from 6% to 9% for metastatic disease. Annually, breast cancer in the Netherlands is responsible for approximately 3100 deaths, 26,000 life years lost, 65,000 Disability Adjusted Life Years (DALYs) and an economic burden of 1.27 billion. CONCLUSIONS: This study provides a comprehensive assessment of the burden of breast cancer and subsequent trends over time in the Netherlands.
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Neoplasias de la Mama/epidemiología , Carcinoma Ductal de Mama/epidemiología , Carcinoma Intraductal no Infiltrante/epidemiología , Años de Vida Ajustados por Calidad de Vida , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/economía , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/patología , Carcinoma Intraductal no Infiltrante/economía , Carcinoma Intraductal no Infiltrante/patología , Costo de Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Persona de Mediana Edad , Países Bajos/epidemiología , Prevalencia , Pronóstico , Sistema de Registros , Tasa de Supervivencia , Carga Tumoral , Adulto JovenRESUMEN
OBJECTIVE: To determine how out-of-pocket costs for adjuvant endocrine therapy (AET) medication affects adherence among newly diagnosed breast cancer survivors with private health insurance who initiate therapy. MATERIALS AND METHODS: We examined medical and pharmacy claims for the 1-year period after initiating AET using the Truven Health Analytics MarketScan database. Adherence was defined as ≥80% proportion of days covered. Mean out-of-pocket costs for AET fill were measured as the sum of copayments, coinsurance, and deductibles and adjusted to 30-day amounts. Using a multivariable logistic regression model we calculated adjusted risk ratios controlling for age, comorbidities, type of surgery, use of chemotherapy and/or radiation therapy, average out-of-pocket costs for other services, and pharmacy use characteristics. RESULTS: Of the 6863 women 64 years and younger who were diagnosed with breast cancer and initiated AET, 73.9% were adherent (proportion of days covered≥80%). A total of 19% of patients had <$5 monthly out-of-pocket costs for AET, 30% had $5 to $9.99, 17% had $10 to $14.99, 10% had $15 to $19.99, and 25% had $20 or greater. Patients with out-of-pocket costs for AET between $10 and $14.99, $15 and $19.99, and >$20 were 6% to 8% less likely to be adherent compared with patients paying <$5.00, after controlling for covariates (P<0.05). Out-of-pocket costs for inpatient, outpatient, and other pharmacy services were not associated with adherence. CONCLUSIONS: A substantial proportion of privately insured patients are nonadherent to AET and out-of-pocket costs for AET medication are significantly associated with a greater likelihood of nonadherence.
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Antineoplásicos Hormonales/economía , Neoplasias de la Mama/economía , Carcinoma Ductal de Mama/economía , Carcinoma Intraductal no Infiltrante/economía , Gastos en Salud/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Cumplimiento de la Medicación/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Antineoplásicos Hormonales/uso terapéutico , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/tratamiento farmacológico , Carcinoma Ductal de Mama/patología , Carcinoma Intraductal no Infiltrante/tratamiento farmacológico , Carcinoma Intraductal no Infiltrante/patología , Femenino , Estudios de Seguimiento , Humanos , Cumplimiento de la Medicación/psicología , Persona de Mediana Edad , Pronóstico , Estudios RetrospectivosRESUMEN
INTRODUCTION: We evaluated the impact of travel distance and insurance status on contralateral prophylactic mastectomy (CPM) rates in breast cancer. METHODS: We queried the National Cancer Data Base (NCDB) for women >18 years of age with a nonmetastatic primary breast cancer of ductal, lobular, or mixed histology. Patient- and facility-specific CPM rates were calculated based on insurance, race, and distance to treatment center. Standard univariable and multivariable regression analysis was performed. RESULTS: Overall, the CPM rate was 6.5% for the 864,105 patients identified. Most patients traveled <20 miles to a treatment center (79.5%) and had private insurance or Medicare (58.3 and 33.4%, respectively). In general, younger, White, non-Hispanic, and privately insured patients residing further from a treatment center was associated with increased rates of CPM. However, distance to the treatment center and insurance type had a greater absolute impact on rates of CPM for Black and Hispanic patients. Absolute CPM rate increases for patients >100 miles from a treatment center compared with those <20 miles from a treatment center were observed to be greater for Black and Hispanic patients (3.5 and 3.9%, respectively) compared with White and non-Hispanic patients (2.5 and 2.6%). Additionally, further patient travel distance was associated with higher treatment center-specific CPM rates. CONCLUSION: Increased travel distance is independently associated with increased rates of CPM for all patients and increased facility-specific rates of CPM. Black and Hispanic patients were found to be more vulnerable to the impact of travel distance and insurance status on rates of CPM.
Asunto(s)
Neoplasias de la Mama/cirugía , Bases de Datos Factuales , Accesibilidad a los Servicios de Salud , Hospitales/estadística & datos numéricos , Cobertura del Seguro , Mastectomía Profiláctica/estadística & datos numéricos , Adolescente , Adulto , Anciano , Neoplasias de la Mama/economía , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/cirugía , Carcinoma Lobular/economía , Carcinoma Lobular/cirugía , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Pronóstico , Adulto JovenRESUMEN
BACKGROUND: Currently, reinterventions for involved margins after breast-conserving surgery remain common. The aim of this study was to assess the capability of the cavity shave margins (CSM) technique to reduce positive margin rates and reoperations compared with simple lumpectomy (SL). The impact of CSM on the various biological portraits of breast cancer and costs were also investigated. METHODS: A retrospective review of 976 consecutive patients from a single center was performed; 164 patients underwent SL and 812 received CSM. All patients were treated with an oncoplastic approach. and involved margins and reoperations were compared for each group. To avoid selection bias, propensity score-matched analysis was performed before applying a logistic regression model. Main outcomes were reanalyzed for each biological portrait, and surgery and hospitalization costs for SL and CSM were compared. RESULTS: Clear margins were found in 98.3% of patients in the CSM group versus 74.4% of patients in the SL group (p < 0.001). The reoperation rate was 18.9% in the SL group and 1.9% in the CSM group (p < 0.001). After propensity score-matched logistic regression, odds ratio (OR) for positive final margin status was 6.2 (95% confidence interval [CI] 2.85-13.46; p < 0.001) without CSM, while OR for reintervention was 5.46 (95% CI 2.21-13.46; p < 0.001). CSM significantly reduced positive margins and reexcisions for Luminal A, Luminal B, and triple-negative breast cancers (p < 0.001, p < 0.001, and p = 0.0137, respectively). SL had higher global costs compared with CSM: 193,630.6 versus 177,830 for 100 treated patients (p = 0.009). CONCLUSIONS: CSM reduces reexcisions, mainly in luminal breast cancers, without increasing costs.
Asunto(s)
Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/cirugía , Carcinoma Lobular/cirugía , Mastectomía Segmentaria/economía , Neoplasia Residual/cirugía , Reoperación , Neoplasias de la Mama Triple Negativas/cirugía , Neoplasias de la Mama/economía , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/patología , Carcinoma Lobular/economía , Carcinoma Lobular/patología , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Invasividad Neoplásica , Neoplasia Residual/economía , Neoplasia Residual/patología , Pronóstico , Puntaje de Propensión , Estudios Retrospectivos , Neoplasias de la Mama Triple Negativas/economía , Neoplasias de la Mama Triple Negativas/patologíaRESUMEN
OBJECTIVE: The aim of the study was to compare costs associated with excision of routine cavity shave margins (CSM) versus standard partial mastectomy (PM) in patients with breast cancer. BACKGROUND: Excision of CSM reduces re-excision rates by more than 50%. The economic implications of this is, however, unclear. METHODS: Between October 21, 2011 and November 25, 2013, 235 women undergoing PM for Stage 0-III breast cancer were randomized to undergo either standard PM ("no shave", n = 116) or have additional CSM taken ("shave", n = 119). Costs from both a payer and a hospital perspective were measured for index surgery and breast cancer surgery-related care through subsequent 90 days. RESULTS: The 2 groups were well-matched in terms of baseline characteristics. Those in the "shave" group had a longer operative time at the initial surgery (median 76 vs 66 min, P < 0.01), but a lower re-excision rate for positive margins (13/119 = 10.9% vs 32/116 = 27.6%, P < 0.01). Actual direct hospital costs associated with operating room time ($1315 vs. $1137, P = 0.03) and pathology costs ($1195 vs $795, P < 0.01) were greater for the initial surgery in patients in the "shave" group. Taking into account the index surgery and the subsequent 90 days, there was no significant difference in cost from either the payer ($10,476 vs $11,219, P = 0.40) or hospital perspective ($5090 vs $5116, P = 0.37) between the "shave" and "no shave" groups. CONCLUSIONS: Overall costs were not significantly different between the "shave" and "no shave" groups due to significantly fewer reoperative surgeries in the former.
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Neoplasias de la Mama/cirugía , Gastos en Salud/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricos , Márgenes de Escisión , Mastectomía Segmentaria/métodos , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/economía , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/cirugía , Carcinoma Intraductal no Infiltrante/economía , Carcinoma Intraductal no Infiltrante/cirugía , Carcinoma Lobular/economía , Carcinoma Lobular/cirugía , Connecticut , Femenino , Estudios de Seguimiento , Humanos , Mastectomía Segmentaria/economía , Persona de Mediana Edad , Estudios Prospectivos , Reoperación , Método Simple Ciego , Resultado del TratamientoRESUMEN
BACKGROUND: With the incidence of breast cancer rising worldwide, we are evaluating the iBreastExam (iBE) (UE LifeSciences Inc.), a handheld breast scanning device that can be utilized by community health workers to screen for breast abnormalities. The purpose of this study is to determine the sensitivity of the iBE in a population undergoing diagnostic breast imaging. METHODS: Adult patients presenting to a breast imaging center for a diagnostic workup were eligible. Patients underwent an iBE exam performed by a trained ultrasound technician followed by their indicated imaging. Demographic, imaging, and biopsy data were recorded. RESULTS: Seventy-eight iBE exams were completed, 77 females and one male with a mean age of 42 (21-79). All patients were evaluated by ultrasound, 52 had diagnostic mammography and 39 had biopsies. Imaging and/or biopsy confirmed a mass (fibroadenoma, cyst, papilloma, myofibroblastoma, fat necrosis, DCIS, or cancer) in 60 patients. Twelve patients had a cancer diagnosed. In total, 342 quadrants were scanned, 77 quadrants had lesions confirmed on imaging, and iBE correctly identified 66 lesions for a sensitivity of 86 % and specificity of 89 %. CONCLUSIONS: This validation study demonstrated excellent sensitivity of iBE for the identification of clinically significant lesions in patients presenting for diagnostic imaging. TRIAL REGISTRATION: A Cost-Effective Handheld Breast Scanner for Use in Low Resource Environments: A Validation Study: NCT02814292 .
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Neoplasias de la Mama/diagnóstico por imagen , Carcinoma Ductal de Mama/diagnóstico por imagen , Carcinoma Intraductal no Infiltrante/diagnóstico por imagen , Fibroadenoma/diagnóstico por imagen , Papiloma/diagnóstico por imagen , Ultrasonografía Mamaria/instrumentación , Ultrasonografía Mamaria/métodos , Adulto , Anciano , Neoplasias de la Mama/economía , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/patología , Carcinoma Intraductal no Infiltrante/economía , Carcinoma Intraductal no Infiltrante/patología , Femenino , Fibroadenoma/economía , Fibroadenoma/patología , Estudios de Seguimiento , Humanos , Mamografía , Persona de Mediana Edad , Invasividad Neoplásica , Estadificación de Neoplasias , Papiloma/economía , Papiloma/patología , Pronóstico , Ultrasonografía Mamaria/economía , Adulto JovenRESUMEN
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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Neoplasias de la Mama/diagnóstico , Carcinoma in Situ/diagnóstico , Carcinoma Ductal de Mama/diagnóstico , Neoplasias de la Mama/economía , Neoplasias de la Mama/cirugía , Carcinoma in Situ/economía , Carcinoma in Situ/patología , Carcinoma in Situ/cirugía , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/patología , Carcinoma Ductal de Mama/cirugía , Análisis Costo-Beneficio , Femenino , Humanos , Cadenas de Markov , Mastectomía Segmentaria/economía , Mastectomía Segmentaria/métodos , Persona de Mediana Edad , Riesgo , Estados UnidosRESUMEN
Most institutions reflexively test all breast core needle biopsy specimens showing ductal carcinoma in situ (DCIS) for estrogen receptor (ER) and progesterone receptor (PR). However, 5 factors suggest that this reflex testing unnecessarily increases costs. First, ER/PR results do not currently impact the next step in standard therapy; namely, surgical excision. Second, a subset of surgical excisions performed for DCIS diagnosed on core needle biopsy will harbor infiltrating mammary carcinoma, which will then need to be retested for ER/PR. Third, because ER and PR labeling is often heterogeneous in DCIS, negative results for ER/PR on small core needle biopsy specimens should logically be repeated on surgical excision specimens with larger amounts of DCIS to be sure that the result is truly negative. Fourth, many patients with pure ER/PR-positive DCIS after surgical excision will decline hormone therapy, so any ER/PR testing of their DCIS is unnecessary. Fifth, PR status in DCIS has no proven independent value. We now examine the unnecessary added costs associated with reflex ER/PR testing of DCIS on core needle biopsy specimens due to these factors. We reviewed 58 core needle biopsies showing pure DCIS that also had a resulting surgical excision specimen at our institution over a period of 2 years. No patient received neoadjuvant hormone therapy. On surgical excision, 5 (8.6%) had only benign findings, 44 (75.9%) had pure DCIS, and 9 (15.5%) had DCIS with invasive mammary carcinoma. The 9 cases with invasive mammary carcinoma in the surgical excision specimen (16%) and the 4 pure DCIS in surgical excision specimens that were ER/PR negative on core needle biopsy would need repeat ER/PR testing. The total unnecessary increased cost of core needle biopsy specimen testing of these 13 cases was $8148.92 ($140/patient for the 58 patients in the study). We found that ER/PR testing results impacted patient management in only 16/49 pure DCIS cases after surgical excision (33%), indicating that ER/PR testing costing $20,685.72 ($357/patient in the study) had been performed unnecessarily. PR testing could have been omitted in the 16 cases in which ER/PR results were used, which would have saved $5014.72, or $86.46 per patient. Extrapolating the increased cost of $583 per DCIS diagnosis on core needle biopsy to 60,000 new cases of DCIS in the United States each year, reflex core needle biopsy ER/PR testing unnecessarily increases costs by approximately $35 million. We recommend that ER/PR not be reflexively ordered on core needle biopsy specimens or surgical excision specimens containing DCIS, but instead that ER alone be performed on surgical excision specimens only when hormone therapy is a serious consideration after medical oncology consultation.
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Biomarcadores de Tumor/análisis , Neoplasias de la Mama/economía , Carcinoma Intraductal no Infiltrante/economía , Receptores de Estrógenos/análisis , Receptores de Progesterona/análisis , Adulto , Anciano , Biopsia con Aguja Gruesa , Neoplasias de la Mama/diagnóstico , Carcinoma Ductal de Mama/diagnóstico , Carcinoma Ductal de Mama/economía , Carcinoma Intraductal no Infiltrante/diagnóstico , Análisis Costo-Beneficio , Femenino , Humanos , Persona de Mediana Edad , Estados UnidosRESUMEN
PURPOSE: Whole breast irradiation after conservative surgery is the standard treatment for invasive breast cancer. Randomized studies indicate that hypofractionation can be equivalent for selected patients. This study focuses on fractionation practice evolution in a single centre, and analyses the economic impact of practice modification. MATERIAL AND METHODS: All prescriptions for invasive breast cancer between January 2010 and June 2014 were analyzed. Female patients 60 years or older, pN0 were considered for the economic study. Patients included in clinical trials or patient with high-grade tumours were excluded from the hypofractionation practice study, because physician could not choose fractionation. We used data from the Medical public health system to calculate cost per fraction and transportation cost. RESULTS: Two thousand thirty one patients were treated; 399 were eligible for the economic study (20%) and 282 for the practice study (14%). Treatment with 25 fractions decreased from 90% to 16% in the first half of 2014. Meanwhile, treatment with 15 or 16 fractions increased from 6% in 2010 to 68% in the first half of 2014. Hypofractionated treatment proportion was 100% with 42.5Gy in 16 fractions in 2010 and 100% 40Gy in 15 fractions in 2014, according to long-term follow-up publication of START trials. Treatment with five fractions remained stable around 7% (4 to 16%), reserved for patients over 80 years (P<0.0001). Based on data from 3451 fractions in 2013, transport cost was calculated at 62 per fraction, in addition to a 170.77 reimbursement per fraction, giving a cost per fraction of 232.77 . CONCLUSION: Practice change led to an increase of hypofractionation in recent years. Hypofractionation may be currently prescribed and may concern 20% of patients. This practice evolution is beneficial for patients and the public health system.
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Neoplasias de la Mama/economía , Neoplasias de la Mama/radioterapia , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/radioterapia , Hipofraccionamiento de la Dosis de Radiación , Anciano , Anciano de 80 o más Años , Femenino , Francia , Humanos , Radioterapia/economía , Mecanismo de Reembolso/economía , Transportes/economíaRESUMEN
BACKGROUND: SSO-ASTRO recently published guidelines defining adequate margins in breast conservation therapy (BCT) as no tumor on ink based on studies demonstrating little difference in local recurrence (LR) with wider margins. We hypothesize that not routinely re-excising close margins results in decreased costs without compromising care. METHODS: A decision tree model was developed for the management of margins after BCT for invasive cancer. Patients were compared among three margin status groups: positive, close (≤2 mm) and negative (>2 mm). Ten publications provided re-excision rates (RER) and LR rates. The model assumed 140,000 BCT/year. Sensitivity analyses determined the most cost-effective strategy. Surgical costs were estimated using 2013 Medicare reimbursement rates. RESULTS: Re-excising close margins was significantly more costly than the alternative, $233.1 million versus $214.3 million, per year in the United States. Total surgical cost was most sensitive to re-excision of close margins-increasing the RER from 0% to 100% resulted in an $18.8 million cost difference. CONCLUSIONS: The strategy of re-excising close margins resulted in a predicted cost of $18.8 million per year. This does not include hospital costs, the cost of surgical complications after re-excision, and underestimates the potential savings by using Medicare reimbursement rates.
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Neoplasias de la Mama/economía , Carcinoma Ductal de Mama/economía , Análisis Costo-Beneficio , Árboles de Decisión , Mastectomía Segmentaria/economía , Recurrencia Local de Neoplasia/economía , Reoperación/economía , Neoplasias de la Mama/patología , Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/patología , Carcinoma Ductal de Mama/cirugía , Femenino , Estudios de Seguimiento , Humanos , Invasividad Neoplásica , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , Neoplasia Residual/economía , Neoplasia Residual/patología , Neoplasia Residual/cirugía , PronósticoRESUMEN
BACKGROUND: To explore the hospitalizations of breast cancer patients undergoing mastectomy, and to provide a basis for management, clinical prevention and treatment. MATERIALS AND METHODS: We conducted an investigation by means of the retrospective survey and the medical records retrieval system, and made out the data of patients suffered from breast cancer in a hospital in Guangzhou from 2004 to 2013, including age, medical payment methods, pathological type, treatment, treatment results, complications, hospitalization days, cost and so on. RESULTS: The average age of the inpatients was 50.14 years old. The main histologic types were infiltrating duct carcinoma (88.06%). The main surgery was modified radical mastectomy (80.41%). The cure rate was 90.80% during the 10 years. The main medical payment method was self-paying (57.28%). The average hospital stay was 13.51 days, and average hospitalization cost was RMB 23,083.66 yuan, proportion of drug fees up to 39.70%. Postoperative complication rate was 0.79%. The self-paying group was with the highest proportion of drug fees (P<0.05), while the free medical service group was with the longest hospitalization days (P<0.05). CONCLUSIONS: The payment methods significantly affected the proportion of drug fees and hospitalization days. The therapeutic effect was satisfactory with less complications and reasonable proportion of drug fees in our hospital.
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Adenocarcinoma Mucinoso/cirugía , Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/cirugía , Carcinoma Lobular/cirugía , Hospitalización/economía , Mastectomía/economía , Adenocarcinoma Mucinoso/economía , Adenocarcinoma Mucinoso/secundario , Adulto , Neoplasias de la Mama/economía , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/economía , Carcinoma Ductal de Mama/secundario , Carcinoma Lobular/economía , Carcinoma Lobular/secundario , China , Femenino , Estudios de Seguimiento , Costos de Hospital , Humanos , Pacientes Internos , Tiempo de Internación , Metástasis Linfática , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Estudios Retrospectivos , Factores de TiempoRESUMEN
ER/PR/Her2 are often reflexively assessed in all core needle biopsies (CNBXs) containing invasive mammary carcinoma (IMC) so that neoadjuvant therapy can be considered. ER/PR/Her2 can be heterogenous, and there is growing consensus that negative results for any of these markers in small CNBXs should be repeated in larger excision specimens (EXS). The frequency and added cost of repeat testing of EXS containing untreated IMC with negative ER/PR/Her2 CNBX results has not previously been studied. We reviewed 198 CNBXs containing IMC, which had reflex ER/PR/Her2 testing and for which there was an EXS for review. We determined the number of cases in which ER/PR/Her2 immunohistochemistry and Her2 fluorescence in situ hybridization were negative on CNBX. Twenty-seven (13.6%) patients received neoadjuvant chemotherapy, and 8 (4%) patients did not have IMC on follow-up EXS, so for them testing the CNBX was necessary. Of the remaining 163 IMCs, 17% were ER negative, and 26% were PR negative, whereas 85% were Her2 negative or equivocal. At our institution, ER/PR were repeated on slightly more than one half of ER/PR-negative tumors, whereas Her2 was repeated on less than one third of Her2-negative/equivocal tumors. Had all negative tests been repeated, the increased cost of testing both the CNBX and EXS would be $100,821. Extrapolating to 230,000 new cases of IMC in the United States each year, the increased cost of repeat testing of all negative ER/PR/Her2 CNBX results would be >$117 million dollars. Limiting reflex testing to ER would decrease the cost of repeat testing to $10 million dollars. We suggest that ER/PR/Her2 should not be reflexively performed on all CNBX specimens containing IMC but instead be routinely performed on EXS and only selectively on CNBX specimens if neoadjuvant chemotherapy is a serious consideration for that individual patient.
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Neoplasias de la Mama/química , Neoplasias de la Mama/economía , Carcinoma Ductal de Mama/química , Carcinoma Ductal de Mama/economía , Costos de la Atención en Salud , Receptor ErbB-2/análisis , Receptores de Estrógenos/análisis , Receptores de Progesterona/análisis , Anciano , Biopsia con Aguja Gruesa/economía , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/patología , Femenino , Humanos , Persona de Mediana EdadRESUMEN
OBJECTIVE: Breast cancer (BC) and metastatic breast cancer (MBC) are significant causes of deaths amongst women worldwide, including developing countries. The cost of treatment in the latter is even more of an issue than in higher income countries. ErbB2 overexpression is a marker of poor prognosis and the goal for targeted therapy. This study was aimed at evaluating the cost-effectiveness in Colombia of ErbB2+ MBC treatment after progression on trastuzumab. METHODS: A decision analytic model was constructed for evaluating such treatment in a hypothetical cohort of ErbB2+MBC patients who progressed after a first scheme involving trastuzumab. The alternatives compared were lapatinib+capecitabine (L+C), and trastuzumab+a chemotherapy agent (capecitabine, vinorelbine or a taxane). Markov models were used for calculating progression-free time and the associated costs. Effectiveness estimators for such therapy were identified from primary studies; all direct medical costs based on national fees-guidelines were included. Sensitivity was analyzed and acceptability curves estimated. A 3 % discount rate and third-payer perspective were used within a 5-year horizon. RESULTS: L+C dominated its comparators. Its cost-effectiveness ratio was COP $49,725,045 per progression-free year. The factors most influencing the results were the alternatives' hazard ratios and the cost of trastuzumab. CONCLUSION: Lapatinib was cost-effective compared to its alternatives for treating MBC after progression on trastuzumab using a Colombian decision analytic model.
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Protocolos de Quimioterapia Combinada Antineoplásica/economía , Neoplasias de la Mama/economía , Carcinoma Ductal de Mama/economía , Receptor ErbB-2/análisis , Adulto , Anciano , Antimetabolitos Antineoplásicos/economía , Antimetabolitos Antineoplásicos/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias de la Mama/tratamiento farmacológico , Capecitabina/administración & dosificación , Capecitabina/economía , Capecitabina/uso terapéutico , Carcinoma Ductal de Mama/tratamiento farmacológico , Colombia , Análisis Costo-Beneficio , Países en Desarrollo , Progresión de la Enfermedad , Supervivencia sin Enfermedad , Resistencia a Antineoplásicos , Femenino , Gastos en Salud , Humanos , Reembolso de Seguro de Salud , Lapatinib , Cadenas de Markov , Persona de Mediana Edad , Honorarios por Prescripción de Medicamentos , Quinazolinas/administración & dosificación , Quinazolinas/economía , Receptor ErbB-2/antagonistas & inhibidores , Taxoides/administración & dosificación , Taxoides/economía , Trastuzumab/administración & dosificación , Vinblastina/administración & dosificación , Vinblastina/análogos & derivados , Vinblastina/economía , VinorelbinaRESUMEN
Objective Breast cancer (BC) and metastatic breast cancer (MBC) are significant causes of deaths amongst women worldwide, including developing countries. The cost of treatment in the latter is even more of an issue than in higher income countries. ErbB2 overexpression is a marker of poor prognosis and the goal for targeted therapy. This study was aimed at evaluating the cost-effectiveness in Colombia of ErbB2+ MBC treatment after progression on trastuzumab. Methods A decision analytic model was constructed for evaluating such treatment in a hypothetical cohort of ErbB2+MBC patients who progressed after a first scheme involving trastuzumab. The alternatives compared were lapatinib+capecitabine (L+C), and trastuzumab+a chemotherapy agent (capecitabine, vinorelbine or a taxane). Markov models were used for calculating progression-free time and the associated costs. Effectiveness estimators for such therapy were identified from primary studies; all direct medical costs based on national fees-guidelines were included. Sensitivity was analyzed and acceptability curves estimated. A 3 % discount rate and third-payer perspective were used within a 5-year horizon. Results L+C dominated its comparators. Its cost-effectiveness ratio was COP $49,725,045 per progression-free year. The factors most influencing the results were the alternatives' hazard ratios and the cost of trastuzumab. Conclusion Lapatinib was cost-effective compared to its alternatives for treating MBC after progression on trastuzumab using a Colombian decision analytic model.
Objetivo El cáncer de seno (CS) y cáncer de seno metastásico (CSM) son importantes causas de muerte entre las mujeres a nivel mundial y en países en vía de desarrollo. En estos últimos los costos de los tratamientos son aún más preocupantes que en países de alto ingreso. La sobreexpresión de ErbB2 es marcador de pobre pronóstico y objetivo de terapias dirigidas. Se evaluó la costo-efectividad de los tratamientos de CSM ErbB2+ en progresión post-trastuzumab en Colombia. Métodos Se desarrolló un modelo analístico de decisiones para evaluar los tratamientos en una cohorte hipotética de CSM ErbB2+ que progresaron después de un primer esquema con trastuzumab. Las alternativas comparadas fueron: lapatinib+capecitabina (L+C), y trastuzumab más un agente quimioterápico (capecitabina, vinorelbinao un taxano). Se usaron modelos de Markov para calcular el tiempo libre de progresión y los costos asociados. Estimaciones de efectividad fueron identificadas de estudios primarios. Se incluyeron todos los costos médicos directos basados en los manuales tarifarios nacionales. Se realizaron análisis de sensibilidad y curvas de aceptabilidad. Se descontaron costos y resultados a una tasa anual de 3 %, la perspectiva de análisis fue del tercer pagador y el horizonte de 5 años. Resultados L+C domina a sus comparadores con un razón de costo-efectividad de COP $49 725 045 por año libre de progresión. Los factores que más influencian los resultados son los hazard ratios de las alternativas y el costo de trastuzumab. Conclusión Lapatinib es costo-efectivo comparado con sus alternativas para el tratamiento del CSM después de la progresión con trastuzumab en el escenario colombiano.