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Benefits and costs of screening and treatment for early breast cancer: development of a basic benefit package |
Kattlove H, Liberati A, Keeler E, Brook R H |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Screening and treatment strategies for early breast cancer.
Economic study type Cost-effectiveness analysis.
Study population A hypothetical health care organisation with an enrolled population of 500,000, in which 360 new cases of breast cancer would be expected each year.
Setting Hospital. The study was carried out in California, USA.
Dates to which data relate Effectiveness and resource use data were collected from studies previously published between 1980 and 1993. The price year was 1993.
Source of effectiveness data Effectiveness data were derived from a review of previously published studies.
Modelling No modelling was undertaken.
Outcomes assessed in the review Regarding screening mammography, only survival was considered. Regarding primary surgery, survival and 4 dimensions of post-surgical health-related quality of life (fear of recurrence, psychological adjustment, body image, and sexuality) were considered. Regarding adjuvant therapy, overall survival was considered. For follow-up care, recurrence rate, survival rate, and health-related quality of life were considered.
Study designs and other criteria for inclusion in the review Studies were selected on the basis of their design. A hierarchy was used which gave preference, in decreasing order, to meta-analyses of randomised trials, individual randomised trials, prospective cohort studies, retrospective cohort studies, and case series.
Sources searched to identify primary studies The authors conducted a search of MEDLINE and added references from other articles and reviews. Other sources included the Surveillance, Epidemiology, and End Results Program, and the US Census.
Criteria used to ensure the validity of primary studies Methods used to judge relevance and validity, and for extracting data Number of primary studies included Approximately 74 studies were included.
Methods of combining primary studies Investigation of differences between primary studies Results of the review The number of lives saved per 1,000 screened at 10 years was 0 for the 40-49 year old group, 1.45 for the 50-59 year old group, 1.81 for the 60-69 year old group, and 0 for the 70-74 year old group. The number of extra days of life per person screened was 0 for the 40-49 year old group, 11.7 for the 50-59 year old group, 9.8 for the 60-69 year old group, and 1.8 for the 70-74 year old group. A more extensive primary surgery procedure did not demonstrate a survival advantage, although breast-conserving surgery was associated with a higher incidence of local recurrence. Patients undergoing breast-conserving surgery had a better body image than those undergoing the more extensive procedure. Adjuvant polychemotherapy for patients younger than 50 years reduced relative mortality by 25%; adjuvant polychemotherapy for those aged 50 years or more reduced relative mortality by 12%, while tamoxifen for 2 years reduced relative mortality by 20%. Most recurrences, when detected, were symptomatic, and routine follow-up testing did not improve survival nor did it seem to influence health-related quality of life.
Measure of benefits used in the economic analysis The number of lives saved was used as the measure of benefits.
Direct costs It was not reported whether direct costs were discounted. Quantities and costs were not reported separately. Direct costs included charges for mammography and charges for evaluating positive mammograms; charges for primary surgery; charges of chemotherapy, blood cell counts and physician visits; and charges for follow-up physician visits and tests. The quantity/cost boundary adopted was that of the health service. The estimation of quantities and costs was based on actual data. Charges were based on Southern California Medicare fees. The price year was 1993.
Statistical analysis of costs Estimated benefits used in the economic analysis Regarding mammography screening, the number of lives saved was 11.9 for the 50-69 year old group, 0 for the 40-49 year old group, and 0 for the 70-74 year old group. The more extensive procedure and breast-conserving surgery followed by radiation therapy provided equal survival. No increased mortality has been found with breast-conserving surgery without radiation therapy. For women younger than 50 years, polychemotherapy reduces mortality by 25%. For women aged 50 years or more, the analysis showed benefits both for polychemotherapy and tamoxifen and indicated that treatment over longer time periods is better. Routine follow-up testing provides no benefit in survival or health-related quality of life.
Cost results Annual/biennial mammography screening had a cost of $3,959,000/$1,979,000 for the 50-69 year old group, $2,922,000/$1,461,000 for the 40-49 year old group, and $825,000/$413,000 for the 70-74 year old group. Breast-conserving surgery and radiation therapy had a cost of $3,284,000 compared with $1,250,000 for the more extensive procedure. For women aged 50 years or less, the costs of adjuvant therapy ranged from $63,000 to $126,000. For women aged 50 years or more, the costs of adjuvant therapy ranged from $150,000 to $450,000. Follow-up care over 5 years incurred significant excess costs.
Synthesis of costs and benefits Mammography screening had a cost of $166,302 per life saved at 10 years for women aged 50-69 years, and a cost of $1,480,000 per life saved at 10 years for women aged 40-49 years. Adjuvant therapy for women aged 50 years or less had a cost between $23,000 and $50,000 per life saved at 10 years. Adjuvant therapy for women aged 50 years or more had a cost between $22,000 and $225,000 per life saved at 10 years.
Authors' conclusions The following plan for the detection and treatment of early breast cancer was recommended:
(1) screening mammography for women aged 50 to 69 years;
(2) choice of mastectomy or breast-conserving surgery with radiation therapy for all women with early breast cancer;
(3) adjuvant therapy for all women at risk of recurrence; and
(4) only clinical follow-up without routine testing for metastatic disease.
CRD COMMENTARY - Selection of comparators The rationale for the choice of the comparators was clear. Validity of estimate of measure of benefit The authors adopted a systematic and thorough approach to identifying suitable literature according to validity criteria. However, given the short time frame of most studies, the authors were unable to examine long-term outcomes. With the exception of surgical treatment, the study did not evaluate psychosocial outcomes of other therapeutic decisions. Health-related quality of life during adjuvant therapy was not considered. Using the number of lives saved at 10 years does not take into account the number of lives lost after 10 years. Validity of estimate of costs Charges as opposed to costs were used and these do not represent true opportunity costs. Patients' costs such as costs of toxicity from chemotherapy and time lost from work were not included. Costs are unlikely to be generalisable to other settings or countries. Other issues Although a good quality review was undertaken to determine effectiveness/benefit data no details were provided about how benefit values were pooled. The generalisability of the benefit results to other settings or countries was not specifically discussed. Bibliographic details Kattlove H, Liberati A, Keeler E, Brook R H. Benefits and costs of screening and treatment for early breast cancer: development of a basic benefit package. Journal of the American Medical Association 1995; 273(2): 142-148 Other publications of related interest 1. Comments in: JAMA 1995;274(5):380-381 and discussion on page 382.
2. Commentary in: ACP Journal Club 1995;123(2):34-35.
3. Bryan S, Brown J, Warren R. Mammography screening: an incremental cost effectiveness analysis of two-view versus one-view procedure in London. Journal of Epidemiology and Community Health 1995;49:70-78.
4. Smith T J, Hillner B E. The efficacy and cost-effectiveness of adjuvant therapy of early breast cancer in pre-menopausal women. Journal of Clinical Oncology 1993;11(4):771-776.
5. Szeto K L, Devlin N J. The cost-effectiveness of mammography screening: evidence from a microsimulation model for New Zealand. Health Policy 1996;38:101-115.
6. Wolstenholme J L, Smith S J, Whynes D K. The costs of treating breast cancer in the United Kingdom: implications for screening. International Journal of Technology Assessment in Health Care 1998;14(2):277-288
Indexing Status Subject indexing assigned by NLM MeSH Adult; Age Factors; Aged; Breast Neoplasms /economics /prevention & Combined Modality Therapy /economics /utilization; Cost-Benefit Analysis; Female; Health Care Costs; Humans; Insurance Benefits; Mammography /economics /utilization; Mass Screening /economics /utilization; Mastectomy /economics /utilization; Middle Aged; Technology Assessment, Biomedical; control /therapy AccessionNumber 21995000119 Date bibliographic record published 30/11/1999 Date abstract record published 30/11/1999 |
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