This study explores the effectiveness and cost-effectiveness of surveillance after breast cancer treatment provided in a hospital-setting versus surveillance embedded in the community-based National Breast Cancer Screening Program (NBCSP).
Using a decision tree, strategies were compared on effectiveness and costs from a healthcare perspective over a 5-year time horizon. Women aged 50–75 without distant metastases that underwent breast conserving surgery in 2003–2006 were selected from the Netherlands Cancer Registry (n = 14,093). Key input parameters were mammography sensitivity and specificity, risk of loco regional recurrence (LRR), and direct healthcare costs. Primary outcome measure was the proportion true test results (TTR), expressed as the positive and negative predictive value (PPV, NPV). The incremental cost-effectiveness ratio (ICER) is defined as incremental costs per TTR forgone.
For the NBCSP-strategy, 13,534 TTR (8 positive; 13,526 negative), and 12,923 TTR (387 positive; 12,536 negative) were found for low and high risks respectively. For the hospital-based strategy, 26,663 TTR (13 positive; 26,650 negative) and 24,883 TTR (440 positive; 24,443 negative) were found for low and high risks respectively. For low risks, the PPV and NPV for the NBCSP-based strategy were 3.31% and 99.88%, and 2.74% and 99.95% for the hospital strategy respectively. For high risks, the PPV and NPV for the NBCSP-based strategy were 64.10% and 98.87%, and 50.98% and 99.71% for the hospital-based strategy respectively. Total expected costs of the NBCSP-based strategy were lower than for the hospital-based strategy (low risk: €1,271,666 NBCSP vs €2,698,302 hospital; high risk: €6,939,813 NBCSP vs €7,450,150 hospital), rendering ICERs that indicate cost savings of €109 (95%CI €95–€127) (low risk) and €43 (95%CI €39–€56) (high risk) per TTR forgone.
Despite expected cost-savings of over 50% in the NBCSP-based strategy, it is nearly 50% lower accurate than the hospital-based strategy, compromising the goal of early detection of LRR to an extent that is unlikely to be acceptable.
Netherlands Comprehensive Cancer Organisation (IKNL). Dutch Cancer Figures n.d. http://www.cijfersoverkanker.nl/. Accessed 1 Jan 2016.
Otto SJ, Fracheboud J, Looman CWN, Broeders MJM, Boer R, Hendriks JHCL, et al. Initiation of population-based mammography screening in Dutch municipalities and effect on breast-cancer mortality: a systematic review. Lancet. 2003;361:1411–7. https://doi.org/10.1016/S0140-6736(03)13132-7. CrossRefPubMed
Netherlands Comprehensive Cancer Organisation (IKNL). National guideline on breast cancer, version: 2.0. 2012.
NICE. Early and locally advanced breast cancer: Follow-up 2009. https://www.nice.org.uk/guidance/cg80/chapter/guidance#follow-up. Accessed 1 Feb 2016.
Cancer Australia. Recommendations for follow-up of women with early breast cancer 2011. http://guidelines.canceraustralia.gov.au/guidelines/early_breast_cancer/ch01s03.php. Accessed 1 Feb 2016.
Runowicz CD, Leach CR, Henry NL, Henry KS, Mackey HT, Cowens-Alvarado RL, et al. American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline. J Clin Oncol. 2015;33:1078–85. https://doi.org/10.1200/JCO.2015.64.3809. CrossRef
Sheppard C. Breast cancer follow-up: literature review and discussion. Eur J Oncol Nurs. 2007. https://doi.org/10.1016/j.ejon.2006.09.001.
van Hezewijk M, Elske van den Akker M, van de Velde CJH, Scholten AN, Hille ETM, van den Akker ME, et al. costs of different follow-up strategies in early breast cancer: a review of the literature. Breast 2012;21:693–700. https://doi.org/10.1016/j.breast.2012.09.009.
Collins RF, Bekker HL, Dodwell DJ. Follow-up care of patients treated for breast cancer: a structured review. Cancer Treat Rev. 2004. https://doi.org/10.1016/S0305-7372(03)00141-5.
Smith IE, Schiavon G. Follow-up tests to detect recurrent disease: Patient’s reassurance or medical need? Breast. 2013;22. https://doi.org/10.1016/j.breast.2013.07.030.
Emery JD, Shaw K, Williams B, Mazza D, Fallon-Ferguson J, Varlow M, et al. The role of primary care in early detection and follow-up of cancer. Nat Rev Clin Oncol. 2014. https://doi.org/10.1038/nrclinonc.2013.212.
Lewis RA, Neal RD, Williams NH, France B, Hendry M, Russell D, et al. Follow-up of cancer in primary care versus secondary care: systematic review. Br J Gen Pract. 2009;59:525–32. https://doi.org/10.3399/bjgp09X453567.
National Institute of Public Health and Environment (RIVM). Bevolkingsonderzoek Borstkanker 2013. http://www.rivm.nl/Onderwerpen/B/Bevolkingsonderzoek_borstkanker. Accessed 1 Feb 2016.
Witteveen A, Vliegen IMH, Sonke GS, Klaase JM, IJzerman MJ, Siesling S. Personalisation of breast cancer follow-up: a time-dependent prognostic nomogram for the estimation of annual risk of locoregional recurrence in early breast cancer patients. Breast Cancer Res Treat. 2015;152:627–36. https://doi.org/10.1007/s10549-015-3490-4. CrossRefPubMedPubMedCentral
Briggs AH, Weinstein MC, Fenwick E a L, Karnon J, Sculpher MJ, Paltiel a D. Model parameter estimation and uncertainty analysis: a report of the ISPOR-SMDM modeling good research practices task force −6. Med Decis Mak. 2012. https://doi.org/10.1177/0272989X12458348.
Houssami N, Abraham LA, Miglioretti DL, Sickles EA, Kerlikowske K, Buist DSM, et al. Accuracy and outcomes of screening mammography in women with a personal history of early-stage breast cancer. JAMA. 2011. https://doi.org/10.1001/jama.2011.188.
Moossdorff M, Van Roozendaal LM, LJ a S, Aebi S, D a C, Dixon JM, et al. Maastricht Delphi consensus on event definitions for classification of recurrence in breast cancer research. J Natl Cancer Inst. 2014;106. https://doi.org/10.1093/jnci/dju288.
Lu WL, Jansen L, Post WJ, Bonnema J, Van de Velde JC, De Bock GH. Impact on survival of early detection of isolated breast recurrences after the primary treatment for breast cancer: a meta-analysis. Breast Cancer Res Treat. 2009. https://doi.org/10.1007/s10549-008-0023-4.
Doyle T, Schultz DJ, Peters C, Harris E, Solin LJ. Long-term results of local recurrence after breast conservation treatment for invasive breast cancer. Int J Radiat Oncol Biol Phys. 2001.
Oh S, Heflin L, Meyerowitz BE, Desmond KA, Rowland JH, Ganz PA. Quality of life of breast cancer survivors after a recurrence: a follow-up study. Breast Cancer Res Treat. 2004;87:45–57. https://doi.org/10.1023/B:BREA.0000041580.55817.5a. CrossRefPubMed
Meisel SF, Pashayan N, Rahman B, Side L, Fraser L, Gessler S, et al. Adjusting the frequency of mammography screening on the basis of genetic risk: attitudes among women in the UK. Breast. 2015. https://doi.org/10.1016/j.breast.2015.02.001.
Brown PM. Personalized medicine and comparative effectiveness research in an era of fixed budgets. EPMA J. 2010. https://doi.org/10.1007/s13167-010-0058-6.
Ghezzi P, Magnanini S. Impact of follow-up testing on survival and health-related quality of life in breast cancer patients. JAMA. 1994;271:1587–92. CrossRef
Geurts SME, De Vegt F, Siesling S, Flobbe K, Aben KKH, Van Der Heiden-Van Der Loo M, et al. Pattern of follow-up care and early relapse detection in breast cancer patients. Breast Cancer Res Treat. 2012;136:859–68. https://doi.org/10.1007/s10549-012-2297-9.
- Shifting breast cancer surveillance from current hospital setting to a community based setting: a cost-effectiveness study
Kelly M. de Ligt
Lotte M. G. Steuten
- BioMed Central
Neu im Fachgebiet Onkologie
Mail Icon II