Cykert Samuel, Phifer Nancy, Hansen Charles
Cecil G. Sheps Center for Health Services Research, the University of North Carolina, Chapel Hill, North Carolina, USA.
Obstet Gynecol. 2004 Sep;104(3):433-42. doi: 10.1097/01.AOG.0000133481.74113.f3.
Given the potential side effects and an uncertain survival benefit, decisions about tamoxifen treatment for the primary prevention of breast cancer remain complex. Primary care providers, including gynecologists, will need to counsel patients regarding this form of preventive care. In this report, we update cost-effectiveness calculations for tamoxifen chemoprevention and establish reasonable parameters for clinicians' use.
We performed a cost-effectiveness analysis that compared women aged 50 years who were treated with tamoxifen for 5 years with an untreated cohort. In the base model, we assumed a 3.4% 5-year breast cancer risk. Quality-of-life estimates for important outcomes (breast cancer, endometrial cancer, deep venous thrombosis, pulmonary embolism, stroke, metastatic cancer, and hot flushes) were obtained from 106 women. Probabilities and costs of outcomes were derived from the Breast Cancer Chemoprevention Trial and other published estimates. Broad sensitivity analyses were performed. Cost per quality-adjusted life-year gained as a result of tamoxifen breast cancer prevention was the main outcome measure.
The use of tamoxifen led to a remaining life expectancy of 26.07 quality-adjusted life-years compared with 25.97 without treatment. The cost per quality-adjusted life-year gained was $43,300. Sensitivity analysis revealed that younger age, the absence of the uterus, higher initial risk of breast cancer, increased fear of curable breast cancer, and reduced tamoxifen cost further favored treatment.
Tamoxifen chemoprevention is cost-effective for women aged 40-50 years who are at significant breast cancer risk. Whether this holds true for older women depends on the initial breast cancer risk, fear of breast cancer, and presence of the uterus.
鉴于他莫昔芬潜在的副作用以及生存获益的不确定性，关于其用于乳腺癌一级预防的治疗决策仍然复杂。包括妇科医生在内的初级保健提供者需要就这种预防形式向患者提供咨询。在本报告中，我们更新了他莫昔芬化学预防的成本效益计算，并为临床医生的使用确定合理参数。
我们进行了一项成本效益分析，将接受他莫昔芬治疗5年的50岁女性与未治疗队列进行比较。在基础模型中，我们假设5年乳腺癌风险为3.4%。从106名女性中获得了重要结局（乳腺癌、子宫内膜癌、深静脉血栓形成、肺栓塞、中风、转移性癌症和潮热）的生活质量估计值。结局的概率和成本来自乳腺癌化学预防试验及其他已发表的估计值。进行了广泛的敏感性分析。他莫昔芬预防乳腺癌所获得的每质量调整生命年成本是主要结局指标。
使用他莫昔芬导致剩余预期寿命为26.07个质量调整生命年，而未治疗组为25.97个。每获得一个质量调整生命年的成本为43,300美元。敏感性分析显示，年龄较小、无子宫、乳腺癌初始风险较高、对可治愈乳腺癌的恐惧增加以及他莫昔芬成本降低进一步支持治疗。
他莫昔芬化学预防对有显著乳腺癌风险的40 - 50岁女性具有成本效益。这对老年女性是否适用取决于初始乳腺癌风险、对乳腺癌的恐惧以及子宫的情况。
