School of Public Health, The University of Hong Kong, Hong Kong SAR, China.
Cancer. 2012 Sep 15;118(18):4394-403. doi: 10.1002/cncr.27448. Epub 2012 Feb 22.
Recommendations about funding of interventions through the full spectrum of the disease often have been made in isolation. The authors of this report optimized budgetary allocations by comparing cost-effectiveness data for different preventive and management strategies throughout the disease course for breast cancer in Hong Kong (HK) Chinese women.
Nesting a state-transition Markov model within a generalized cost-effectiveness analytic framework, costs and quality-adjusted life-years (QALYs) were compared to estimate average cost-effectiveness ratios for the following interventions at the population level: biennial mass mammography (ages 40-69 years or ages 40-79 years), reduced waiting time for postoperative radiotherapy (by 15% or by 25%), adjuvant endocrine therapy (either upfront aromatase inhibitor [AI] therapy or sequentially with tamoxifen followed by AI) in postmenopausal women with estrogen receptor-positive disease, targeted immunotherapy in those with tumors that over express human epidermal growth factor receptor 2, and enhanced palliative services (either at home or as an inpatient). Usual care for eligible patients in the public sector was the comparator.
In descending order, the optimal allocation of additional resources for breast cancer would be the following: a 25% reduction in waiting time for postoperative radiotherapy (in US dollars: $5000 per QALY); enhanced, home-based palliative care ($7105 per QALY); adjuvant, sequential endocrine therapy ($17,963 per QALY); targeted immunotherapy ($62,092 per QALY); and mass mammography screening of women ages 40 to 69 years ($72,576 per QALY).
Given the lower disease risk and different age profiles of patients in HK Chinese, among other newly emergent and emerging economies with similar transitioning epidemiologic profiles, the current findings provided direct evidence to support policy decisions that may be dissimilar to current Western practice.
针对整个疾病过程中的不同预防和管理策略，人们经常会分别提出关于干预措施资金投入的建议。本报告的作者通过将香港（中国）女性乳腺癌患者在整个疾病过程中的不同预防和管理策略的成本效益数据进行比较，对预算分配进行了优化。
将状态转移马尔可夫模型嵌套在广义成本效益分析框架内，以比较人群水平上以下干预措施的成本和质量调整生命年（QALY），以估计其平均成本效益比：每两年一次的乳房 X 光普查（年龄 40-69 岁或 40-79 岁）、将术后放疗的等候时间减少 15%或 25%、辅助内分泌治疗（绝经后雌激素受体阳性疾病患者中使用芳香化酶抑制剂[AI] upfront 治疗或先用他莫昔芬再用 AI）、针对肿瘤过度表达人表皮生长因子受体 2 的靶向免疫治疗、以及增强姑息治疗服务（在家中或住院）。公共部门符合条件的患者的常规护理为对照组。
乳腺癌的额外资源最佳分配顺序如下：将术后放疗的等候时间减少 25%（以美元计：每 QALY 5000 美元）；增强、家庭为基础的姑息治疗（每 QALY7105 美元）；辅助、序贯内分泌治疗（每 QALY17963 美元）；靶向免疫治疗（每 QALY62092 美元）；对 40 至 69 岁的女性进行大规模乳房 X 光筛查（每 QALY72576 美元）。
鉴于香港华人患者的疾病风险较低，年龄分布也不同，以及其他具有类似转变流行病学特征的新兴经济体，这些新出现的经济体，本研究结果为可能与当前西方实践不同的政策决策提供了直接证据。
