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Economic Evaluation of Breast Cancer Treatment: Considering the Value of Patient Choice

Daniel Polsky, Jeanne S. Mandelblatt, Jane C. Weeks, Laura Venditti, Yi-Ting Hwang, Henry A. Glick, Jack Hadley, Kevin A. Schulman

From the University of Pennsylvania, Philadelphia, PA; Georgetown University, Washington, DC; Dana-Farber Cancer Institute, Boston, MA; and the Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Durham, NC.

Address reprint requests to Daniel Polsky, PhD, Division of General Internal Medicine, University of Pennsylvania, Blockley Hall 1212, Philadelphia, PA 19104-6021; email: polsky{at}mail.med.upenn.edu.

Purpose: To use 5 years of primary data to compare the incremental cost-effectiveness of breast conservation and radiation versus mastectomy with the restriction of choice to a single therapy versus providing a choice of either therapy.

Patients and Methods: We evaluated a random retrospective cohort of 2,517 Medicare beneficiaries treated for newly diagnosed stage I or II breast cancer from 1992 through 1994. The outcome measures were quality-adjusted life-years (QALYs) and 5-year medical costs. Risk and propensity score adjustments were used in the analysis.

Results: A breast conservation and radiation regimen has significantly higher costs than mastectomy in the first year after surgery; the adjusted 5-year costs are $14,054 (95% confidence interval, $9,791 to $18,312) greater than those of mastectomy. The adjusted incremental cost-effectiveness ratio comparing breast conservation and radiation to mastectomy was $219,594 per QALY for the comparison of the two strategies. If the possibility of patient choice from maintaining the availability of multiple treatments versus restricting choice to mastectomy alone provides a quality-of-life gain of 0.031 QALYs, then the cost-effectiveness ratio of this choice option is $80,440 per QALY.

Conclusion: The current system of providing a choice between mastectomy and breast conservation surgery is economically attractive when the economic analysis includes the benefit of patient choice of treatment.

Supported by grant no. HS08395 from the Agency for Health Care Policy and Research (Agency for Healthcare Research and Quality), United States Department of Health and Human Services grant no. 17-94-J-4212 from the Department of the Army, and cooperative agreement no. U01/CA88283A from the National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD.

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