A comparison of four treatment strategies for ductal carcinoma in situ using decision analysis

Bordeleau, Louise; Rakovitch, Eileen; Naimark, David; Pritchard, Kathleen I.; Ackerman, Ida; Sawka, Carol

doi:10.1002/1097-0142(20010701)92:1<23::aid-cncr1287>3.0.co;2-y

Cited by 9 publications

(5 citation statements)

References 35 publications

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“…Our analysis extends the previous work to reflect choices in current clinical practice by providing information about margin status [11][12][13]. One of the previous studies indicates that the best strategy for DCIS treatment depends on patients' preferences [12]. Our conclusions corroborate theirs.…”

Section: Discussionsupporting

confidence: 85%

“…The results provide an avenue to aid patients and physicians in decision making since margin information is usually available. Our analysis extends the previous work to reflect choices in current clinical practice by providing information about margin status [11][12][13]. One of the previous studies indicates that the best strategy for DCIS treatment depends on patients' preferences [12].…”

Section: Discussionmentioning

confidence: 63%

“…Several studies have used a decision model to examine DCIS treatment strategies, but none modeled DCIS as a heterogeneous disease with different recurrence risks [11][12][13]. There has also been interest in identifying prognostic factors to determine low-risk DCIS patients [14,15].…”

Section: Introductionmentioning

confidence: 99%

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Incorporating margin status information in treatment decisions for women with ductal carcinoma in situ: a decision analysis

Wang

Kuntz

Tuttle

et al. 2010

Breast Cancer Res Treat

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To integrate margin status information into the decision to undergo radiation therapy (RT) following breast-conserving surgery (BCS) for women with ductal carcinoma in situ (DCIS). We developed a decision-analytic Markov model to project quality-adjusted life years (QALYs) for a hypothetical cohort of 55-year-old women with DCIS over a lifetime horizon treated with or without RT following BCS. We estimated the transition probabilities of local DCIS and invasive recurrences based on the margin status (free, close, or positive) from a systematic literature review. Other probability estimates and utilities were collected from the published literature. Using the conditions defined in this model, expected QALYs after BCS alone were better than those after BCS with RT under the free-margin scenario (15.72 vs. 15.58) and worse in the close-margin (15.44 vs. 15.50) and positive-margin scenarios (15.20 vs. 15.33). The probability of receiving a salvage mastectomy varied from 10 to 28%, depending on margin status and treatment. One-way sensitivity analyses showed that the optimal treatment was sensitive to patients' preferences and RT side effects. Probabilistic sensitivity analyses revealed that BCS alone would be the best strategy in 54% of the cases under the free-margin scenario, 48% under the close-margin scenario, and 44% under the positive-margin scenario. This study illustrates that margin status is able to provide supplementary information on the decision of DCIS treatment. Our analyses also highlight the importance of patients' preferences in decision making. Our findings suggest that RT is not necessary for all patients with DCIS undergoing BCS.

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Section: Discussionsupporting

confidence: 85%

Section: Discussionmentioning

confidence: 63%

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Incorporating margin status information in treatment decisions for women with ductal carcinoma in situ: a decision analysis

Wang

Kuntz

Tuttle

et al. 2010

Breast Cancer Res Treat

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“…Utilities for health states after salvage mastectomy and distant metastases were extracted from published literature 5. The effect of tamoxifen on utility has been estimated in terms of a disutility of 0.05,12 which we used in our model with the assumption of an additive relationship among utilities (and we tested this inclusion in sensitivity analyses).…”

Section: Methodsmentioning

confidence: 99%

Partial-Breast Irradiation Versus Whole-Breast Irradiation for Early-Stage Breast Cancer: A Cost-Effectiveness Analysis

Sher¹,

Wittenberg

Suh

et al. 2009

International Journal of Radiation Oncology*Biology*Physics

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Purpose-Accelerated partial breast irradiation (PBI) is a new treatment paradigm for early-stage breast cancer. Although PBI may lead to higher local recurrence rates, it may be cost-effective because of better tolerability and lower cost. We aimed to determine the incremental costeffectiveness of PBI compared to whole breast radiation therapy (WBRT) for estrogen-receptor positive postmenopausal women treated for early-stage breast cancer.Methods and Materials-We developed a Markov model to describe health states in the 15 years following radiotherapy (RT) for early-stage breast cancer. External beam (EB) and MammoSite (MS) PBI were considered and assumed to be equally effective but carried different costs. Patients received tamoxifen but not chemotherapy. Utilities, recurrence risks, and costs were adapted from the literature; the baseline utility for no disease after RT was set at 0.92. Probabilistic sensitivity analyses were performed to model uncertainty in the PBI hazard ratio (HR), recurrence pattern, and patient utilities. Costs (in 2004 $US) and QALYs were discounted at 3%/year.Results-The incremental cost-effectiveness ratio for WBRT compared to EB-PBI was $630,000/ QALY; WBRT strongly dominated MS-PBI. One-way sensitivity analysis found the results were sensitive to PBI HR, recurrence pattern, baseline recurrence risk, and NED-PBI utility values. Probabilistic sensitivity showed that EB-PBI was the most cost-effective technique over a wide range of assumptions and societal willingness-to-pay values.Conclusions-EB-PBI was the most cost-effective strategy for postmenopausal women with early-stage breast cancer. Unless the quality-of-life after MS-PBI proves to be superior, it is unlikely to be cost-effective.

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“…Most patients with DCIS are now offered breast-conserving surgery (BCS) (Bordeleau et al, 2001) in marked contrast to the practice two decades ago when mastectomy was the standard treatment. Breast-conserving surgery, even with the addition of adjuvant radiotherapy, is associated with local recurrence (LR) rates of up to 10% at 4 years George et al, 2000;Julien et al, 2000) compared to 1 -2% after mastectomy, with about half of all recurrences being invasive cancers (Solin et al, 2001).…”

mentioning

confidence: 99%

Biological response to hormonal manipulation in oestrogen receptor positive ductal carcinoma in situ of the breast

Boland¹,

McKeown²,

Chan³

et al. 2003

Br J Cancer

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Adjuvant antioestrogen therapy with tamoxifen is recommended for all women following breast-conserving surgery for ductal carcinoma in situ (DCIS) to reduce local recurrence, despite 50% of lesions being oestrogen receptor (OR) negative. We have investigated the response to hormone manipulation in DCIS by studying changes in epithelial proliferation and progesterone receptor (PR) expression as surrogate molecular markers of treatment effects in DCIS of known OR status. Women were identified who had undergone diagnostic core biopsy followed by surgery for DCIS 14 -41 days later. Ki67 (a measure of epithelial cell proliferation) and PR expression were determined by immunohistochemistry on paired paraffin sections of the core biopsy and operative specimens for each patient, with OR and HER-2 measured on the operative specimen. Women were divided into three groups according to whether they had changed hormone therapy (stopped hormone replacement therapy (HRT), group 1), continued taking HRT (group 2) or were not taking HRT (group 3) between core biopsy and surgery. In OR-positive (but not in OR-negative) DCIS after oestrogen withdrawal (group 1), a fall in the mean cell proliferation (Po0.01) was observed. A fall in PR expression between core biopsy and surgery was also seen in this group (P ¼ 0.02). No change in either mean cell proliferation or PR expression was seen in the other two groups in OR-positive or -negative DCIS. The fall in proliferation and PR expression occurred regardless of HER-2 status. In conclusion, a biological response to hormone manipulation is only seen in OR-positive DCIS tumours. Any clinical value of antioestrogen therapy is likely to be restricted to this group.

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A comparison of four treatment strategies for ductal carcinoma in situ using decision analysis

Cited by 9 publications

References 35 publications

Incorporating margin status information in treatment decisions for women with ductal carcinoma in situ: a decision analysis

Incorporating margin status information in treatment decisions for women with ductal carcinoma in situ: a decision analysis

Partial-Breast Irradiation Versus Whole-Breast Irradiation for Early-Stage Breast Cancer: A Cost-Effectiveness Analysis

Biological response to hormonal manipulation in oestrogen receptor positive ductal carcinoma in situ of the breast

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