Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, ON, Canada.
Value Health. 2013 Jul-Aug;16(5):729-39. doi: 10.1016/j.jval.2013.03.1625. Epub 2013 Jul 1.
Adjuvant chemotherapy decisions in early breast cancer are complex. The 21-gene assay can potentially aid such decisions, but costs US $4175 per patient. Adjuvant! Online is a freely available decision aid. We evaluate the cost-effectiveness of using the 21-gene assay in conjunction with Adjuvant! Online, and of providing adjuvant chemotherapy conditional upon risk classification.
A probabilistic Markov decision model simulated risk classification, treatment, and the natural history of breast cancer in a hypothetical cohort of 50-year-old women with lymph node-negative, estrogen receptor- and/or progesterone receptor-positive, human epidermal growth factor receptor 2/neu-negative early breast cancer. Cost-effectiveness was considered from an Ontario public-payer perspective by deriving the lifetime incremental cost (2012 Canadian dollars) per quality-adjusted life-year (QALY) for each strategy, and the probability each strategy is cost-effective, assuming a willingness-to-pay of $50,000 per QALY.
The 21-gene assay has an incremental cost per QALY in patients at low, intermediate, or high Adjuvant Online! risk of $22,440 (probability cost-effective 78.46%), $2,526 (99.40%), or $1,111 (99.82%), respectively. In patients at low (high) 21-gene assay risk, adjuvant chemotherapy increases (reduces) costs and worsens (improves) health outcomes. For patients at intermediate 21-gene assay risk and low, intermediate, or high Adjuvant! Online risk, chemotherapy has an incremental cost per QALY of $44,088 (50.59%), $1,776 (77.65%), or $1,778 (82.31%), respectively.
The 21-gene assay appears cost-effective, regardless of Adjuvant! Online risk. Adjuvant chemotherapy appears cost-effective for patients at intermediate or high 21-gene assay risk, although this finding is uncertain in patients at intermediate 21-gene assay and low Adjuvant! Online risk.
早期乳腺癌的辅助化疗决策非常复杂。21 基因检测可能有助于此类决策，但每位患者的费用为 4175 美元。Adjuvant! Online 是一种免费的决策辅助工具。我们评估了联合使用 21 基因检测和 Adjuvant! Online，以及根据风险分类提供辅助化疗的成本效益。
概率马尔可夫决策模型模拟了 50 岁淋巴结阴性、雌激素受体和/或孕激素受体阳性、人表皮生长因子受体 2/neu 阴性早期乳腺癌女性的风险分类、治疗和乳腺癌自然史。通过从安大略省公共支付者的角度计算每种策略的每例质量调整生命年（QALY）的增量成本（2012 加元），以及每种策略具有成本效益的概率（假设每 QALY 愿意支付 50,000 加元），来考虑成本效益。
在 Adjuvant Online! 低、中、高风险的患者中，21 基因检测的增量成本每 QALY 分别为 22,440 加元（概率具有成本效益 78.46%）、2,526 加元（99.40%）或 1,111 加元（99.82%）。在 21 基因检测低（高）风险的患者中，辅助化疗增加（降低）成本并恶化（改善）健康结果。对于 21 基因检测中风险和 Adjuvant! Online 低、中、高风险的患者，化疗的增量成本每 QALY 分别为 44,088 加元（50.59%）、1,776 加元（77.65%）或 1,778 加元（82.31%）。
无论 Adjuvant! Online 风险如何，21 基因检测似乎都具有成本效益。对于 21 基因检测中风险或高风险的患者，辅助化疗具有成本效益，尽管在 21 基因检测中风险和 Adjuvant! Online 低风险的患者中，这一发现尚不确定。
