Hillner B E, Bear H D, Fajardo L L
Massey Cancer Center, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298, USA.
Acad Radiol. 1996 Apr;3(4):351-60. doi: 10.1016/s1076-6332(96)80256-x.
We examined the clinical and economic trade-offs of shifting from surgical excisional biopsy to stereotaxic core breast biopsy for evaluating non-palpable, mammographically detected breast lesions.
A decision analysis model compared strategies beginning with excisional or stereotaxic core biopsy for hypothetical cohorts of 1,000 women. All women with negative initial biopsies had a 6-month follow-up mammogram. Sensitivities and specificities were based on the literature and expert estimates. Pretest probabilities of invasive cancer and in situ cancer were each 10% based on mammographic features. Adjusted costs were based on an audit of patients evaluated at the Medical College of Virginia and physician relative value units.
Per 1,000 women, with an expected rate of 100 invasive and 100 in situ cancers, the stereotaxic core biopsy strategy would initially miss 6.7 invasive and 12.4 in situ cases. Most of these would be detected at 6-month follow-ups. Of the women having a stereotaxic core biopsy, 75.7% avoided a surgical procedure. Using stereotaxic core biopsy saved $804 per woman. Continuing to initially use surgical biopsy, total management costs were an additional $42,100 per each case of early detected invasive or in situ cancer. A speculative sensitivity analysis, in which the prognosis of invasive cancer was worse if diagnosis was delayed by 6 months, indicated that surgical biopsy had an incremental cost of $156,700 per additional life year gained.
Using conservative estimates for the false-negative rate of stereotaxic core breast biopsy, widespread use of stereotaxic biopsy is projected to have substantial cost savings with a slight compromise in the rate of early detection. Whether the decremental cost-effectiveness is acceptable is dependent on the natural history of cancers whose diagnosis is delayed.
我们研究了将用于评估乳腺钼靶检查发现的不可触及乳腺病变的手术切除活检改为立体定向核心针穿刺活检的临床和经济权衡。
一个决策分析模型比较了针对1000名女性假设队列从切除活检或立体定向核心针穿刺活检开始的策略。所有初始活检结果为阴性的女性均进行了6个月的随访乳腺钼靶检查。敏感度和特异度基于文献和专家估计。根据乳腺钼靶特征，浸润性癌和原位癌的预测试概率均为10%。调整后的成本基于对弗吉尼亚医学院评估的患者的审计以及医生相对价值单位。
每1000名女性中，预计有100例浸润性癌和100例原位癌，立体定向核心针穿刺活检策略最初会漏诊6.7例浸润性癌和12.4例原位癌。其中大多数将在6个月的随访中被发现。在进行立体定向核心针穿刺活检的女性中，75.7%避免了手术。使用立体定向核心针穿刺活检每名女性节省804美元。继续最初使用手术活检，每例早期发现的浸润性或原位癌的总管理成本额外增加42,100美元。一项推测性敏感性分析表明，如果诊断延迟6个月浸润性癌的预后更差，手术活检每多获得一个生命年的增量成本为156,700美元。
使用对立体定向核心针穿刺活检假阴性率的保守估计，预计广泛使用立体定向活检可大幅节省成本，但在早期检测率上会有轻微折衷。成本效益的降低是否可接受取决于诊断延迟的癌症的自然史。
