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Researchers examine cost-effectiveness and quality of life following surgery for early breast cancer

Early-stage breast cancer is treated equally effectively by mastectomy (surgical removal of the entire breast), or breast-conserving surgery followed by radiation treatment (BCSRT). Two studies supported by the Agency for Healthcare Research and Quality (HS08395) and led by Jeanne S. Mandelblatt, M.D., of Georgetown University, examined the cost-effectiveness of these treatments and patients' quality of life after either surgery.

In the first study, the researchers concluded that the current practice of giving older women with early stage breast cancer a choice of BCSRT or mastectomy was cost effective. The second study demonstrated that, with the exception of surgical removal of armpit lymph nodes to determine cancer spread, how older women were treated during their care, not the therapy itself, was the most important determinant of long-term quality of life. The two studies are discussed here.

Polsky, D., Mandelblatt, J.S., Weeks, J.C., and others (2003, March). "Economic evaluation of breast cancer treatment: Considering the value of patient choice." Journal of Clinical Oncology 21, pp. 1139-1146.

Giving older women a choice of BCSRT or mastectomy for early- stage breast cancer is economically attractive, according to this study. The researchers found that BCSRT cost over $10,000 more than mastectomy in the first year after surgery. But after the first year, costs stabilized for both groups at about $6,000 per year. After adjusting for differences in patient age, stage of cancer, other coexisting medical conditions, and other factors, 5-year costs for BCSRT were $14,054 greater than those of mastectomy.

Using a traditional cost-effectiveness analysis, which used differences in costs and quality-adjusted life years (QALYs) to compare mastectomy and BCSRT, BCSRT cost $219,594 per QALY. In this case, BCSRT would not be considered an economically attractive option relative to mastectomy. However, when patient choice of either option over mastectomy alone was factored into the cost-effectiveness analysis, BCSRT provided a quality-of-life gain of 0.031 QALY at $80,440 per QALY. This indicates that giving women a choice of treatment for early breast cancer, which is the current standard of care, is cost effective.

Choice may also result in improved cost-effectiveness. A $1,289 reduction on top of a 0.03 increase in QALYs would lower the incremental cost-effectiveness ratio of BCSRT to $50,000 per QALY. These findings were based on retrospective evaluation of a random group of 2,517 Medicare beneficiaries treated for newly diagnosed stage I or II breast cancer from 1992 through 1994. The researchers measured QALYs and 5-year medical costs. Overall, 1,813 women underwent mastectomy, and 704 women received BCSRT. The BCSRT women were younger, healthier, and more economically advantaged.

Mandelblatt, J.S., Edge, S.B., Meropol, N.J., and others (2003, March). "Predictors of long-term outcomes in older breast cancer survivors: Perceptions versus patterns of care." Journal of Clinical Oncology 21(5), pp. 855-863.

With the exception of surgical removal of armpit lymph nodes (axillary node dissection), used to detect spread of breast cancer, type of treatment for local breast cancer did not affect outcomes of older women in this study. However, the processes of care, particularly having a choice of treatments and positive perceptions of care delivery, were associated with better long-term quality of life and care satisfaction. For example, women who perceived provider bias against older age or who felt that they had no choice of treatment reported significantly more bodily pain, lower mental health scores, and less general satisfaction than other women. These same factors, as well as perceived provider racial bias (particularly by black women), were also significantly associated with diminished satisfaction with the medical care system.

Women's physical outcomes were most strongly associated with prior health. However, axillary node dissection increased the risk of arm problems (for example, swelling and impaired mobility) four-fold, and had a long-term impact on physical functioning. Overall, breast conservation and mastectomy yielded equal survival in women of all ages with early-stage tumors. Apart from axillary dissection, these two approaches resulted in comparable long-term general physical and mental function. Thus, attempts to improve the quality of care for the growing population of breast cancer survivors should focus on improving the process of care, conclude the researchers.

They conducted telephone surveys with a random sample of 1,812 Medicare-insured women 67 years of age and older, who were 3, 4, and 5 years post-treatment for stage I or II breast cancer. They used regression analysis to estimate the adjusted risk of decreases in physical and mental health functioning by treatment. In a subset of 732 women, they used additional data to examine arm problems, impact of cancer on the women's lives, and care satisfaction, controlling for baseline health, perceptions of ageism and racism, demographic and clinical factors, geographic region, and surgery year.

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