Decision curve analysis is a suitable method for evaluating alternative diagnostic and prognostic strategies that has advantages over other commonly used measures and techniques.

Background: Decision curve analysis is a novel method for evaluating diagnostic tests, prediction models and molecular markers. It combines the mathematical simplicity of accuracy measures, such as sensitivity and specificity, with the clinical applicability of decision analytic approaches. Most critically, decision curve analysis can be applied directly to a data set, and does not require the sort of external data on costs, benefits and preferences typically required by traditional decision analytic techniques.

Purpose-Radical nephrectomy (RN), compared with partial nephrectomy (PN), increases the risk of chronic kidney disease, a significant risk factor for cardiovascular (CV) events and death. Given equivalent oncologic efficacy in patients with small renal tumors (RTs), RN may result in overtreatment. We analyzed a population-based cohort of patients to determine if RN is associated with an increase in CV events and mortality compared with PN.Materials and Methods-Using Surveillance, Epidemiology, and End Results (SEER) cancer registry data linked with Medicare claims, we identified 2991 patients older than 65 years of age treated with RN or PN for RTs 4 cm or smaller between 1995 and 2002. Primary end points of CV events and overall survival were assessed using Kaplan-Meier survival estimation, Cox proportional hazards regression, and negative binomial regression.Results-A total of 2547 (81%) patients underwent RN and 556 (19%) underwent PN. During a median follow-up of 4 years, 609 patients had a CV event and 892 patients died. Adjusting for preoperative demographic and comorbid variables, RN was associated with an increased risk of overall mortality (hazard ratio [HR] 1.38, P<0.01) and a 1.4 times greater number of CV events after surgery (P<0.05). RN, however, was not associated with an increased risk of time to first CV event (HR 1.21, P=0.10) or CV death (HR 0.95, P=0.84).Conclusion-RN, currently the most common treatment for small RTs, may be associated with significant, adverse treatment effects compared with PN. PN should be considered for most patients with small RTs.

Background Testing has been advocated for all persons with newly diagnosed colorectal cancer to identify families with the Lynch syndrome, an autosomal dominant cancer-predisposition syndrome that is a paradigm for personalized medicine. Objective To estimate the effectiveness and cost-effectiveness of strategies to identify the Lynch syndrome, with attention to sex, age at screening, and differential effects for probands and relatives. Design Markov model that incorporated risk for colorectal, endometrial, and ovarian cancers. Data Sources Published literature. Target Population All persons with newly diagnosed colorectal cancer and their relatives. Time Horizon Lifetime. Perspective Third-party payer. Intervention Strategies based on clinical criteria, prediction algorithms, tumor testing, or up-front germline mutation testing, followed by tailored screening and risk-reducing surgery. Outcome Measures Life-years, cancer cases and deaths, costs, and incremental cost-effectiveness ratios. Results of Base-Case Analysis The benefit of all strategies accrued primarily to relatives with a mutation associated with the Lynch syndrome, particularly women, whose life expectancy could increase by approximately 4 years with hysterectomy and salpingo-oophorectomy and adherence to colorectal cancer screening recommendations. At current rates of germline testing, screening, and prophylactic surgery, the strategies reduced deaths from colorectal cancer by 7% to 42% and deaths from endometrial and ovarian cancer by 1% to 6%. Among tumor-testing strategies, immunohistochemistry followed by BRAF mutation testing was preferred, with an incremental cost-effectiveness ratio of $36 200 per life-year gained. Results of Sensitivity Analysis The number of relatives tested per proband was a critical determinant of both effectiveness and cost-effectiveness, with testing of 3 to 4 relatives required for most strategies to meet a threshold of $50 000 per life-year gained. Immunohistochemistry followed by BRAF mutation testing was preferred in 59% of iterations in probabilistic sensitivity analysis at a threshold of $100 000 per life-year gained. Screening for the Lynch syndrome with immunohistochemistry followed by BRAF mutation testing only up to age 70 years cost $44 000 per incremental life-year gained compared with screening only up to age 60 years, and screening without an upper age limit cost $88 700 per incremental life-year gained compared with screening only up to age 70 years. Limitation Other types of cancer, uncertain family pedigrees, and genetic variants of unknown significance were not considered. Conclusion Widespread colorectal tumor testing to identify families with the Lynch syndrome could yield substantial benefits at acceptable costs, particularly for women with a mutation associated with the Lynch syndrome who begin regular screening and have risk-reducing surgery. The cost-effectiveness of such testing depends on the participation rate among relatives at risk for the Lynch syndrome. Primary...

For older patients with advanced CRC, preferences for prognostic information and for an active role in treatment decision making are not easily predictable. Physicians' perceptions are often inconsistent with patients' stated preferences. Explicit discussion of preferred decision-making styles may improve patient-physician encounters.

Background Survivors of head and neck squamous cell carcinoma (HNSCC) face excess mortality from multiple causes. Methods We used population-based Surveillance, Epidemiology, and End Results (SEER) cancer registry data to evaluate the causes of death in patients with non-metastatic HNSCC diagnosed between 1992 and 2005 who survived at least three years from diagnosis (long-term survivors). We used competing-risks proportional hazards regression to estimate probabilities of death from causes: HNSCC, second primary malignancy (SPM) excluding HNSCC, cardiovascular disease (CVD), and other causes. Results We identified 35,958 3-year survivors of HNSCC with a median age at diagnosis of 60 years (range 18 to 100 years) and a median follow-up of 7.7 years (range 3 to 18 years). There were 13,120 deaths during the study period. Death from any cause at 5 and 10 years was 15.4% (95% confidence interval [CI], 15.0% to 15.8%) and 41.0% (95% CI, 40.4% to 41.6%), respectively. There were 3,852 HNSCC deaths including both primary and subsequent head and neck tumors. The risk of death from HNSCC was greater in patients with nasopharynx or hypopharynx cancer and in patients with locally advanced disease. SPM was the leading cause of non-HNSCC death, and the most common sites of SPM death were lung (53%), esophagus (10%), and colorectal (5%) cancer. Conclusion Many long-term HNSCC survivors die from cancers other than HNSCC and from non-cancer causes. Routine follow-up care for HNSCC survivors should expand beyond surveillance for recurrence and new head and neck cancers.

It is more cost-effective to use FISH alone or as confirmation of all positive HercepTest results, rather than using FISH to confirm only weakly positive results or using HercepTest alone. When multiple tests are available to identify treatment candidates, test characteristics may have a substantial impact on the aggregate costs and effectiveness of treatment.

This analysis suggests a survival benefit from adjuvant chemotherapy in older women with HR-negative breast cancer. The benefit of chemotherapy is most pronounced in the patients most likely to be selected for treatment, including those with involved lymph nodes or other high-risk disease characteristics.