Ya Chen Tina Shih

Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society

IMPORTANCE Breast cancer is a leading cause of premature mortality among US women. Early detection has been shown to be associated with reduced breast cancer morbidity and mortality. OBJECTIVE To update the American Cancer Society (ACS) 2003 breast cancer screening guideline for women at average risk for breast cancer. PROCESS The ACS commissioned a systematic evidence review of the breast cancer screening literature to inform the update and a supplemental analysis of mammography registry data to address questions related to the screening interval. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms. EVIDENCE SYNTHESIS Screening mammography in women aged 40 to 69 years is associated with a reduction in breast cancer deaths across a range of study designs, and inferential evidence supports breast cancer screening for women 70 years and older who are in good health. Estimates of the cumulative lifetime risk of false-positive examination results are greater if screening begins at younger ages because of the greater number of mammograms, as well as the higher recall rate in younger women. The quality of the evidence for overdiagnosis is not sufficient to estimate a lifetime risk with confidence. Analysis examining the screening interval demonstrates more favorable tumor characteristics when premenopausal women are screened annually vs biennially. Evidence does not support routine clinical breast examination as a screening method for women at average risk. RECOMMENDATIONS The ACS recommends that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years (strong recommendation). Women aged 45 to 54 years should be screened annually (qualified recommendation). Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation). Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation). Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation). The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation). CONCLUSIONS AND RELEVANCE These updated ACS guidelines provide evidence-based recommendations for breast cancer screening for women at average risk of breast cancer. These recommendations should be considered by physicians and women in discussions about breast cancer screening.

American Cancer Society lung cancer screening guidelines

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Incidence, Treatment Costs, and Complications of Lymphedema After Breast Cancer Among Women of Working Age: A 2-Year Follow-Up Study

PURPOSE This study estimated the economic burden of breast cancer-related lymphedema (BCRL) among working-age women, the incidence of lymphedema, and associated risk factors. METHODS We used claims data to study an incident cohort of breast cancer patients for the 2 years after the initiation of cancer treatment. A logistic regression model was used to ascertain factors associated with lymphedema. We compared the medical costs and rate of infections likely associated with lymphedema between a woman with BCRL and a matched control. We performed nonparametric bootstrapping to compare the unadjusted cost differences and estimated the adjusted cost differences in regression analysis. RESULTS Approximately 10% of the 1,877 patients had claims indicating treatment of lymphedema. Predictors included treatment with full axillary node dissection (odds ratio [OR] = 6.3, P < .001) and chemotherapy (OR = 1.6, P = .01). A geographic variation was observed; women who resided in the West were more likely to have lymphedema claims than those in the Northeast (OR = 2.05, P = .01). The matched cohort analysis demonstrated that the BCRL group had significantly higher medical costs (

Association between treatment with brachytherapy vs whole-breast irradiation and subsequent mastectomy, complications, and survival among older women with invasive breast cancer.

14,877 to

Use of Radiation Therapy in the Last 30 Days of Life Among a Large Population-Based Cohort of Elderly Patients in the United States

23,167) and was twice as likely to have lymphangitis or cellulitis (OR = 2.02, P = .009). Outpatient care, especially mental health services, diagnostic imaging, and visits with moderate or high complexity, accounted for the majority of the difference. CONCLUSION Although the use of claims data may underestimate the true incidence of lymphedema, women with BCRL had a greater risk of infections and incurred higher medical costs. The substantial costs documented here suggest that further efforts should be made to elucidate reduction and prevention strategies for BCRL.

Economic evaluations of medical care interventions for cancer patients: how, why, and what does it mean?

CONTEXT Brachytherapy is a radiation treatment that uses an implanted radioactive source. In recent years, use of breast brachytherapy after lumpectomy for early breast cancer has increased substantially despite a lack of randomized trial data comparing its effectiveness with standard whole-breast irradiation (WBI). Because results of long-term randomized trials will not be reported for years, detailed analysis of clinical outcomes in a nonrandomized setting is warranted. OBJECTIVE To compare the likelihood of breast preservation, complications, and survival for brachytherapy vs WBI among a nationwide cohort of older women with breast cancer with fee-for-service Medicare. DESIGN Retrospective population-based cohort study of 92,735 women aged 67 years or older with incident invasive breast cancer, diagnosed between 2003 and 2007 and followed up through 2008. After lumpectomy 6952 patients were treated with brachytherapy vs 85,783 with WBI. MAIN OUTCOME MEASURES Cumulative incidence and adjusted risk of subsequent mastectomy (an indicator of failure to preserve the breast) and death were compared using the log-rank test and proportional hazards models. Odds of postoperative infectious and noninfectious complications within 1 year were compared using the χ(2) test and logistic models. Cumulative incidences of long-term complications were compared using the log-rank test. RESULTS Five-year incidence of subsequent mastectomy was higher in women treated with brachytherapy (3.95%; 95% CI, 3.19%-4.88%) vs WBI (2.18%; 95% CI, 2.04%-2.33%; P < .001) and persisted after multivariate adjustment (hazard ratio [HR], 2.19; 95% CI, 1.84-2.61, P < .001). Brachytherapy was associated with more frequent infectious (16.20%; 95% CI, 15.34%-17.08% vs 10.33%; 95% CI, 10.13%-10.53%; P < .001; adjusted odds ratio [OR], 1.76; 1.64-1.88) and noninfectious (16.25%; 95% CI, 15.39%-17.14% vs 9.00%; 95% CI, 8.81%-9.19%; P < .001; adjusted OR, 2.03; 95% CI, 1.89-2.17) postoperative complications; and higher 5-year incidence of breast pain (14.55%, 95% CI, 13.39%-15.80% vs 11.92%; 95% CI, 11.63%-12.21%), fat necrosis (8.26%; 95% CI, 7.27-9.38 vs 4.05%; 95% CI, 3.87%-4.24%), and rib fracture (4.53%; 95% CI, 3.63%-5.64% vs 3.62%; 95% CI, 3.44%-3.82%; P ≤ .01 for all). Five-year overall survival was 87.66% (95% CI, 85.94%-89.18%) in patients treated with brachytherapy vs 87.04% (95% CI, 86.69%-87.39%) in patients treated with WBI (adjusted HR, 0.94; 95% CI, 0.84-1.05; P = .26). CONCLUSION In a cohort of older women with breast cancer, treatment with brachytherapy compared with WBI was associated worse with long-term breast preservation and increased complications but no difference in survival.

Comparative effectiveness of robot-assisted versus open radical prostatectomy cancer control

PURPOSE Our goal was to evaluate use and associated costs of radiation therapy (RT) in the last month of life among those dying of cancer. METHODS We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare linked databases to analyze claims data for 202,299 patients dying as a result of lung, breast, prostate, colorectal, and pancreas cancers from 2000 to 2007. Logistic regression modeling was used to conduct adjusted analyses of potential impacts of demographic, health services, and treatment-related variables on receipt of RT and treatment with greater than 10 days of RT. Costs were calculated in 2009 dollars. RESULTS Among the 15,287 patients (7.6%) who received RT in the last month of life, its use was associated with nonclinical factors such as race, gender, income, and hospice care. Of these patients, 2,721 (17.8%) received more than 10 days of treatment. Nonclinical factors that were associated with greater likelihood of receiving more than 10 days of RT in the last 30 days of life included: non-Hispanic white race, no receipt of hospice care, and treatment in a freestanding, versus a hospital-associated facility. Hospice care was associated with 32% decrease in total costs of care in the last month of life among those receiving RT. CONCLUSION Although utilization of RT overall was low, almost one in five of patients who received RT in their final 30 days of life spent more than 10 of those days receiving treatment. More research is needed into physician decision making regarding use of RT for patients with end-stage cancer.

Costs of uncontrolled chemotherapy-induced nausea and vomiting among working-age cancer patients receiving highly or moderately emetogenic chemotherapy

While the past decade has seen the development of multiple new interventions to diagnose and treat cancer, as well as to improve the quality of life for cancer patients, many of these interventions have substantial costs. This has resulted in increased scrutiny of the costs of care for cancer, as well as the costs relative to the benefits for cancer treatments. It is important for oncologists and other members of the cancer community to consider and understand how economic evaluations of cancer interventions are performed and to be able to use and critique these evaluations. This review discusses the components, main types, and analytic issues of health economic evaluations using studies of cancer interventions as examples. We also highlight limitations of these economic evaluations and discuss why members of the cancer community should care about economic analyses.

Trends in the Cost and Use of Targeted Cancer Therapies for the Privately Insured Nonelderly: 2001 to 2011.

BACKGROUND Robot-assisted radical prostatectomy (RARP) remains controversial, and no improvement in cancer control outcomes has been demonstrated over open radical prostatectomy (ORP). OBJECTIVE To examine population-based, comparative effectiveness of RARP versus ORP pertaining surgical margin status and use of additional cancer therapy. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective observational study of 5556 RARP and 7878 ORP cases from 2004 to 2009 from Surveillance Epidemiology and End Results-Medicare linked data. INTERVENTION RARP versus ORP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Propensity-based analyses were performed to minimize treatment selection biases. Generalized linear regression models were computed for comparison of RP surgical margin status and use of additional cancer therapy (radiation therapy [RT] or androgen deprivation therapy [ADT]) by surgical approach. RESULTS AND LIMITATIONS In the propensity-adjusted analysis, RARP was associated with fewer positive surgical margins (13.6% vs 18.3%; odds ratio [OR]: 0.70; 95% confidence interval [CI], 0.66-0.75), largely because of fewer RARP positive margins for intermediate-risk (15.0% vs 21.0%; OR: 0.66; 95% CI, 0.59-0.75) and high-risk (15.1% vs 20.6%; OR: 0.70; 95% CI, 0.63-0.77) disease. In addition, RARP was associated with less use of additional cancer therapy within 6 mo (4.5% vs 6.2%; OR: 0.75; 95% CI, 0.69-0.81), 12 mo (OR: 0.73; 95% CI, 0.62-0.86), and 24 mo (OR: 0.67; 95% CI, 0.57-0.78) of surgery. Limitations include the retrospective nature of the study and the absence of prostate-specific antigen levels to determine biochemical recurrence. CONCLUSIONS RARP is associated with improved surgical margin status relative to ORP for intermediate- and high-risk disease and less use of postprostatectomy ADT and RT. This has important implications for quality of life, health care delivery, and costs. PATIENT SUMMARY Robot-assisted radical prostatectomy (RP) versus open RP is associated with fewer positive margins and better early cancer control because of less use of additional androgen deprivation and radiation therapy within 2 yr of surgery.

Mammography Capacity : Impact on Screening Rates and Breast Cancer Stage at Diagnosis

Chemotherapy‐induced nausea and vomiting (CINV) is among the most feared side effects of cancer treatment. Poorly controlled CINV may lead to additional office visits or emergency room admissions, thus increasing the overall costs of cancer care. The objective of the project was to estimate the societal costs of uncontrolled CINV among working‐age cancer patients.