Levine Cancer Institute, Atrium Health, Charlotte, NC.
Southeast Radiation Oncology Group, Charlotte, NC.
JCO Oncol Pract. 2021 Aug;17(8):e1055-e1074. doi: 10.1200/OP.20.00992. Epub 2021 May 10.
Adjuvant therapy in patients with ductal carcinoma in situ who undergo partial mastectomy remains controversial, particularly for low-risk patients (60 years or older, estrogen-positive, tumor extent < 2.5 cm, grade 1 or 2, and margins ≥ 3 mm). We performed a cost-effectiveness analysis comparing three strategies: no adjuvant treatment after surgery, a five-fraction course of accelerated partial breast irradiation using intensity-modulated radiation therapy (accelerated partial breast irradiation [APBI]-alone), or APBI plus an aromatase inhibitor for 5 years.
Outcomes including local recurrence, distant metastases, and survival as well as toxicity data were modeled by a patient-level Markov microsimulation model, which were validated against trial data. Costs of treatment and possible adverse events were included from the societal perspective over a lifetime horizon, adjusted to 2019 US dollars and extracted from Medicare reimbursement data. Quality-adjusted life-years (QALYs) were calculated based on utilities extracted from the literature.
No adjuvant therapy was the least costly approach ($5,744), followed by APBI-alone ($11,070); combined therapy was costliest ($16,052). Adjuvant therapy resulted in slightly higher QALYs (no adjuvant, 11.320; APBI-alone, 11.343; and combination, 11.381). In the base case, no treatment was the cost-effective strategy, with an incremental cost-effectiveness ratio of $239,109/QALY for APBI-alone and $171,718/QALY for combined therapy. The incremental cost-effectiveness ratio for combined therapy compared with APBI-alone was $131,949. Probabilistic sensitivity analyses found that no therapy was cost effective (defined as $100,000/QALY of lower) in 63% of trials, APBI-alone in 19%, and the combination in 18%.
No adjuvant therapy represents the most cost-effective approach for postmenopausal women 60 years or older who receive partial mastectomy for low-risk ductal carcinoma in situ.
对于接受部分乳房切除术的导管原位癌患者，辅助治疗仍然存在争议，特别是对于低危患者（60 岁或以上，雌激素阳性，肿瘤范围<2.5cm，分级 1 或 2，切缘≥3mm）。我们进行了一项成本效益分析，比较了三种策略：手术后不进行辅助治疗、使用调强放疗的 5 个疗程加速部分乳房照射（APBI 单药治疗）或 APBI 加 5 年芳香酶抑制剂。
通过患者水平的马尔可夫微模拟模型对局部复发、远处转移和生存等结果以及毒性数据进行建模，并根据试验数据进行验证。从社会角度考虑，在终生范围内纳入了治疗成本和可能的不良事件，根据 2019 年的美元进行了调整，并从医疗保险报销数据中提取。根据文献中提取的效用计算了质量调整生命年（QALY）。
不进行辅助治疗是最具成本效益的方法（$5744），其次是 APBI 单药治疗（$11070）；联合治疗最昂贵（$16052）。辅助治疗略微提高了 QALY（不治疗，11.320；APBI 单药治疗，11.343；联合治疗，11.381）。在基础情况下，不治疗是具有成本效益的策略，APBI 单药治疗的增量成本效益比为$239109/QALY，联合治疗的增量成本效益比为$171718/QALY。与 APBI 单药治疗相比，联合治疗的增量成本效益比为$131949。概率敏感性分析发现，在 63%的试验中，不治疗（定义为低于 10 万美元/QALY）具有成本效益，APBI 单药治疗有 19%，联合治疗有 18%。
对于接受部分乳房切除术的低危导管原位癌、60 岁或以上的绝经后女性，不进行辅助治疗是最具成本效益的方法。
