Hillner B E, Smith T J
Department of Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond.
N Engl J Med. 1991 Jan 17;324(3):160-8. doi: 10.1056/NEJM199101173240305.
In 1988 the National Cancer Institute issued a Clinical Alert that has been widely interpreted as recommending that all women with node-negative breast cancer receive adjuvant chemotherapy. Acceptance of this recommendation is controversial, since many women who would not have a recurrence would be treated.
Using a decision-analysis model, we studied the cost effectiveness of chemotherapy in cohorts of 45-year-old and 60-year-old women with node-negative breast cancer by calculating life expectancy as adjusted for quality of life. The analysis evaluated different scenarios of the benefit of therapy: improved disease-free survival for five years, with a lesser effect on overall survival (base line); a lifelong benefit from chemotherapy; and a benefit in disease-free survival with no change in overall survival by year 10. The base-line analysis assumed a 30 percent reduction in the relative risk of recurrence for five years after treatment.
For the 45-year-old woman, the base-line analysis found an average lifetime benefit from chemotherapy of 5.1 quality-months at a cost of $15,400 per quality-year. The 60-year-old women gained 4.0 quality-months at a cost of $18,800 per quality-year. Under the more and less optimistic scenarios, the benefit of chemotherapy varied from 1.4 to 14.0 quality-months for both groups.
Chemotherapy substantially increases the quality-adjusted life expectancy of an average woman at a cost comparable to that of other widely accepted therapies. This benefit decreases markedly if the changes in long-term survival are less than in disease-free survival. Given its uncertain duration, the benefit may be too small for many women to choose chemotherapy. Selective use of chemotherapy to maximize the benefit to individual patients may be possible with refinements in risk stratification and explicit assessment of the patients' risk preferences.
1988年美国国立癌症研究所发布了一项临床警报，该警报被广泛解读为建议所有淋巴结阴性的乳腺癌女性接受辅助化疗。接受这一建议存在争议，因为许多不会复发的女性也会接受治疗。
我们使用决策分析模型，通过计算经生活质量调整的预期寿命，研究了45岁和60岁淋巴结阴性乳腺癌女性队列中化疗的成本效益。该分析评估了不同治疗获益情景：无病生存改善五年，对总生存影响较小（基线）；化疗带来终身获益；无病生存获益且到第10年总生存无变化。基线分析假设治疗后五年复发相对风险降低30%。
对于45岁女性，基线分析发现化疗的平均终身获益为5.1个质量月，每个质量年成本为15,400美元。60岁女性获得4.0个质量月，每个质量年成本为18,800美元。在更乐观和更不乐观的情景下，两组化疗的获益从1.4到14.0个质量月不等。
化疗大幅提高了普通女性经质量调整的预期寿命，成本与其他广泛接受的疗法相当。如果长期生存的变化小于无病生存的变化，这种获益会显著降低。鉴于其持续时间不确定，对许多女性来说，这种获益可能太小以至于无法选择化疗。通过改进风险分层和明确评估患者的风险偏好，有可能选择性地使用化疗以使个体患者的获益最大化。
