Open AccessActive Monitoring Versus Immediate Treatment of Women With Localised, Low-Risk Ductal Carcinoma In Situ: Does It Make Economic Sense?
Author(s) -
Hannah L. Bromley,
Timothy J. Roberts,
Dennis Petrie,
Bruce Mann,
D. Rea,
Carolyn Nickson
Publication year - 2018
Publication title -
journal of global oncology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.002
H-Index - 17
ISSN - 2378-9506
DOI - 10.1200/jgo.18.67900
Subject(s) - overdiagnosis , medicine , ductal carcinoma , breast cancer , cohort , quality adjusted life year , mammography , cost effectiveness , intensive care medicine , cancer , risk analysis (engineering)
Background: Controversy persists about the overdiagnosis of low risk breast cancers identified by breast cancer screening programs. Low risk ductal carcinoma in situ (DCIS) is a noninvasive breast condition with an uncertain risk of invasive progression. Standard management consists of immediate surgical treatment, with or without radiotherapy and adjuvant therapy. Active monitoring of low risk DCIS via annual mammography is proposed as an alternative strategy to immediate surgery to reduce the harm of overdiagnosis, whereby the disease is only treated upon disease progression. However, the costs and benefits of active monitoring are not well researched in the breast cancer setting. Aim: To assess the cost-effectiveness of active monitoring versus immediate surgical management in women diagnosed with low grade ductal carcinoma in situ (DCIS). Methods: A Markov state transition model was constructed for a theoretical cohort of women aged 50 years and over with low risk DCIS over a lifetime horizon. A cost-utility analysis was performed to compare a strategy of observation (active monitoring) versus immediate surgical treatment using an annual time cycle. Transition probabilities, costs and utilities were obtained from national mortality and cost data, published meta-analyses, primary data collection of utilities and expert opinion. A healthcare perspective was adopted to present the results. Primary outcomes were assessed in terms of cost per quality-adjusted-life-year (cost per QALY). Multiple sensitivity analyses were undertaken to determine effect of parameter uncertainty on results. Results: The cumulative costs and QALYs for each age cohort are presented. Active monitoring is a cost-effective strategy for the management of low risk breast cancer in older women with comorbid conditions. Sensitivity analyses revealed the ICERs for all women to be affected by baseline probability of disease progression, age, cost of surgery and utility. Conclusion: Conservative management of ductal carcinoma in situ via active monitoring may be cost-effective compared with immediate surgical treatment in a selected cohort of older women with low risk disease.