A benefits package for breast cancer includes selective screening, choice of surgery, adjuvant therapy, and no routine follow-up
ACP J Club. 1995 Sept-Oct;123:35. doi:10.7326/ACPJC-1995-123-2-035
Kattlove H, Liberati A, Keeler E, Brook RH. Benefits and costs of screening and treatment for early breast cancer. Development of a basic benefit package. JAMA. Jan
To assess the costs and benefits of screening mammography, primary surgery, adjuvant therapy, and follow-up care in early breast cancer to recommend a theoretic benefits package.
Studies were identified through MEDLINE (1980 to 1993) and bibliographies of relevant articles and studies. Other sources were Surveillance, Epidemiology, and End Results Program data; U.S. Census data; and 1993 Southern California Medicare fees.
Meta-analyses; randomized controlled trials (RCT); and cohort, case-control, and case-series studies were selected. Studies were weighted according to methodologic strength.
Costs and cost per life-year saved were calculated using age-specific survival data. When a survival benefit was evident (mammography and adjuvant therapy), costs for those interventions were calculated and compared with life-years gained. When no survival benefit was identified (type of primary surgery or routine testing for metastatic disease), costs were calculated on a cost-per-case basis. Overall, costs were compared with benefits in the context of a hypothetical health care organization of 500 000 persons.
Biennial mammographic screening was cost-effective for women aged 50 to 69 years. More frequent screening and screening for older or younger women were not cost-effective. Offering a choice of mastectomy or breast-conserving surgery with radiation was associated with acceptable costs for women of all ages. The use of most standard adjuvant therapies for women at risk for recurrence was cost-effective. The addition of chemotherapy to tamoxifen in postmenopausal women was the most costly. Routine follow-up testing for metastatic disease was not cost-effective compared with simple clinical follow-up.
A basic benefit plan that includes the following is recommended for the detection and early diagnosis of breast cancer: routine mammography only for women aged 50 to 69 years of age, choice of primary treatment with either mastectomy or breast-conserving surgery plus radiation, adjuvant drug therapy for women at risk for recurrence, and clinical follow-up without extensive routine testing for metastatic disease.
Source of funding: Not stated.
For article reprint: Dr. R.H. Brook, RAND Corporation, 1700 Main Street, Post Office Box 2138, Santa Monica, CA 90407-2138. FAX 310-393-4818.
The article by Kerlikowske and colleagues provides important information that should help resolve the current controversy over the role of screening mammography in women < 50 years of age. This elegant meta-analysis clearly shows a survival benefit for screening mammography in women between the ages of 50 and 74 years. A 26% reduction in mortality was identified in this group of women after 7 to 9 years of follow-up, regardless of screening interval or number of mammographic views (single vs. double). In contrast, no evidence of a survival benefit was seen among women between the ages of 40 and 49 years; an overall nonsignificant risk reduction of 7% was identified. A nonsignificant increase in risk (2%) was identified at 7 to 9 years of follow-up, and a nonsignificant reduction in risk of 17% appeared after 10 to 12 years of follow-up. The authors suggested that the latter finding reflected the fact that younger women became postmenopausal with prolonged surveillance and that the late benefits were a result of screening women while they were postmenopausal or more than 50 years old and not a result of screening women in their early forties.
Although reducing breast cancer mortality among younger women is highly desirable, the results of this meta-analysis clearly show that the routine use of mammographic screening in women aged 40 to 49 years will not achieve this goal. As was so clearly pointed out by the authors, the issue is not low statistical power, it is simply that mammographic screening does not reduce breast cancer mortality in this group of women. Continued recommendations that population-based mammographic screening should be done in younger women cannot be justified by the existing evidence. The health care resources currently used for this activity would probably have a greater effect on breast cancer mortality if they were allocated to the development of new screening techniques for these younger women; to the evaluation of preventive strategies, such as anti-estrogen and dietary fat reduction; or to the development of new treatment strategies.
The article by Kattlove and colleagues examined the costs and benefits of screening and treatment for early breast cancer from the perspective of a hypothetical health care organization of 500 000 persons. Using data available in the literature, they modeled the beneficial effects of screening mammography in older women, adjuvant chemotherapy in premenopausal women, and adjuvant hormonochemotherapy in postmenopausal women. Using conservative approaches to costing that considered only the "up-front" costs of these treatments and not the costs saved as a result of prevention of metastatic breast cancer, they clearly show acceptable costs associated with mammographic screening in women aged 50 to 69 years and with some forms of adjuvant drug treatment. Had the investigators considered the treatment of metastatic disease, the resulting costs would be even more acceptable. The investigators have also shown a policy of offering a choice of primary surgical treatment (lumpectomy with radiation vs mastectomy) to be associated with acceptable cost.
In contrast, 2 approaches to management—mammographic screening in women aged < 50 years and routine investigation for metastatic disease in patients who have completed primary treatment—have not been shown to improve clinical outcomes and could not be justified from a cost perspective. This observation is important because it shows the negative cost effect of 2 common interventions that are often considered justified because they "do no harm." The harm may come from the drain of health care dollars away from interventions that do improve outcomes. The costing data provide additional justification, if any is really needed, for not offering these interventions as part of routine clinical practice.
A common message in these 2 articles is that sometimes it is best to do nothing. This may be a difficult message for compassionate, patient-oriented clinicians to accept, particularly when dealing with a devastating illness like breast cancer, but these articles suggest that the time may have come to do just that.
Pamela J. Goodwin, MD, MSc
Mount Sinai Hospital Toronto, Ontario