Health system costs of metastatic breast cancer.

To assess the costs of treating patients with incurable breast cancer, all health system costs during the interval from diagnosis of first recurrence or metastasis until death for 75 female subjects randomly selected from those known to have died of breast cancer in British Columbia, Canada between July 1, 1995 and December 31, 1996, were identified. Costs were determined from several databases within the British Columbia (BC) Ministry of Health, as well as from BC Cancer Agency patient charts. The mean total cost to the health system was CDN $36,474.33 (95% confidence interval $29,752-$43,196) per subject. The mean costs were highest for the youngest age group and lowest for the middle age group, but these only differed by $2,300. Inpatient costs accounted for the greatest proportion of the total, over 50% in all age groups. This data may be valuable in assessing the cost-effectiveness of interventions that are known to affect mortality due to breast cancer.

Compliance with practice guidelines for node-negative breast cancer.

PURPOSE: Practice guidelines for cancer management have been in use in the province of British Columbia (BC), Canada, since the mid 1970s. To evaluate practice guideline compliance, treatment received was compared with treatment recommended in a population-based cohort of women with breast cancer. METHODS: All incident cases (n = 939) of invasive, pathologically node-negative breast cancer diagnosed in 1991 were identified from the BC Cancer Registry. Treatment details were abstracted from cancer clinic records for cases referred to the BC Cancer Agency (BCCA) (n = 661) and original source documents for nonreferred cases. Management decisions were considered compliant if the patient received the recommended treatment or was entered onto a randomized trial of the modality being assessed. RESULTS: Overall compliance with adjuvant therapy guidelines was 97% for radiotherapy, 96% for chemotherapy, and 89% for tamoxifen. An oncology specialist was consulted by 94% of patients with an indication for adjuvant treatment and by 58% of those without an indication (odds ratio [OR] = 10.7; 95% confidence interval, 7.0 to 16.4). Compliance with a guideline to deliver radiotherapy was 95%; with chemotherapy, 77%; and with tamoxifen, 68%. Compliance with a guideline that stated no adjuvant treatment was indicated was 99% for radiotherapy, 98% for chemotherapy, and 92% for tamoxifen. Noncompliance among patients with an indication for treatment was related to nonreferral to an oncology specialist and less complete implementation of guideline changes in the community as compared with cancer center practices. CONCLUSION: Compliance was high, but scheduled updating and more effective community implementation could further improve consistency of care.

Variations in breast conservation surgery for women with axillary lymph node negative breast cancer in British Columbia.

A population-based study was conducted including all women diagnosed in British Columbia in 1991 with invasive node negative breast cancer (n = 942) in order to identify factors associated with variation in use of breast conserving surgery (BCS) and to determine if provincial practice guidelines were followed. Patient, disease, treatment and physician-specific information was abstracted from medical records and original source documents. 413 (44%) patients received BCS (51% and 23% in surgical candidates and non-candidates, respectively). Significant independent factors associated with BCS included patients' age, residence, family income, tumour size, tumour location, and extent of ductal carcinoma in-situ. Age and income had a significant interaction with stronger income effects in older women. A strong surgeon effect was observed which was not explained by measured surgeon attributes. Expansion of radiation treatment facilities may help address access issues. Further examination of the patient-physician relationship and of ways to assist patients in decision making is needed.

Effect of acetylsalicylic acid on radiation and cosmetic results after conservative surgery for early breast cancer: a randomized trial.

BACKGROUND AND PURPOSE: Acetylsalicylic acid (ASA) can reduce the incidence of stroke and myocardial infarction by inhibiting platelet-fibrin thrombi in small blood vessels. To determine if ASA could reduce late effects of radiation therapy mediated by damage to small blood vessels, a prospective, placebo-controlled, double-blind trial was conducted in women with early breast cancer, receiving radiotherapy to the conserved breast. MATERIALS AND METHODS: Cosmetic outcome and late radiotherapy effects were recorded prospectively for 186 women with T1 or T2, pathologically node-negative breast cancer treated with breast conservation and randomized to receive ASA (325 mg daily) or placebo for 1 year from the start of radiation therapy. Radiation was a tangent pair to the breast alone delivering a modal dose of 44 Gy in 16 daily fractions in 22-25 days. RESULTS: Median follow-up is 6.5 years. The use of ASA has not had any effect on the acute (erythema, edema or discomfort) or late (induration, telangiectasia) effects of radiotherapy (all P > 0.10), the patients' or physicians' assessment of the cosmetic outcome (all P > 0.25) or rates of breast recurrence (P > 0.25). CONCLUSION: ASA cannot be recommended to improve the outcome of radiotherapy complementing breast conserving surgery.

Late cosmetic results of short fractionation for breast conservation.

BACKGROUND AND PURPOSE: The number of fractions of radiation therapy (RT) used after breast conserving surgery varies widely and accounts for a significant proportion of the workload in a modern radiotherapy department. Internationally, 'standard' therapy ranges from 3 to 7 weeks of daily treatment with or without a boost. Short RT schedules have the attraction of reducing workload but raise concern about an increased risk of late effects and poorer cosmetic outcome. MATERIALS AND METHODS: In a randomized trial, 186 women with T1 or T2, pathologically node-negative breast cancer had cosmetic and various normal tissue effects data collected prospectively. The breast RT prescription was 44 Gy in 16 daily fractions to a tangent pair. RESULTS: Median follow-up is 6.7 years. Actuarial 5-year breast recurrence was 6%. Overall cosmetic results at 5 years were good or excellent in 89% and 96% as reported by physicians and patients, respectively, and were stable between 2 and 5 years. Breast discomfort, erythema, edema and induration were related to both surgery and RT. At 5 years, 20% had breast discomfort, 18% had induration, 6% had erythema and 3% had some degree of breast edema. Fewer patients had these effects at 5 years than immediately after primary surgery. The presence of induration prior to starting RT was associated with a greater likelihood of breast induration 3 or more years following RT (P = 0.02). Thirteen percent of patients, generally those with large breasts, developed mild inframammary telangiectasia by 5 years. CONCLUSIONS: Results are comparable to those reported from centers employing more conventional fractionation. Short fractionation produces acceptable cosmetic results for the majority of women if there are no contraindications to RT and in the absence of significant post-operative breast induration.