- Email: [email protected]
1–51 Cost Minimization Study of Image-Guided Core Biopsy Versus Surgical Excisional Biopsy for Women With Abnormal Mammograms
ofsky Performance Status (KPS) index, the Medical Outcomes Study 36-item Short Form (SF-36), the Hospital Anxiety and Depression Scale, the Zarit Burden Inventory, FAMCARE, and the Medical Outcomes Study Social Support Survey and were given every 3 months during the palliative period (KPS > 50) and every 2 weeks during the terminal phase of the patient’s illness (KPS ≤ 50). Financial costs were also obtained through questionnaires at each assessment. Findings.—More than half of the caregivers were male (55%) and the patient’s spouse or partner (52%), with a mean age of 53 years (range, 26-83 years). At the start of the palliative period, the caregivers’ mean physical functioning
score was better than that of the patients, and mean scores on mental functioning were similar between the 2 groups. Similar proportions of caregivers and patients were depressed (11% and 12%) at that time, but significantly more caregivers than patients were anxious (35% vs 19%, P = 0.009). By the start of the terminal phase, the proportion of caregivers who were depressed had increased to 30% vs 9%, P < 0.02) and the perceivedburden score had risen from that at the beginning of the palliative period. This burden, scored by the Zarit Burden Inventory, was the most important predictor of both anxiety and depression. Among employed caregivers, 69% reported some form of adverse impact on work, and 77%
reported missing work because of caregiving responsibilities during the terminal period. Prescription drugs were the most significant component of the financial burden. Conclusions.—Caregivers experienced increases in depression and perceived burden as patients’ functional status declined. Strategies are needed to help reduce the psychosocial, occupational, and economic burden associated with caregiving.
1–51
all downstream costs from the time of biopsy through definitive surgical treatment. Methods.—Clinical and cost data were collected for all 1,121 patients who underwent stereotactic core biopsy and all 501 patients who underwent surgical excisional biopsy at the authors’ institution between 1996 and 1998. Stereotactic core biopsy was performed for calcified lesions and for architectural distortions; surgical excisional biopsy was used when the core biopsy findings suggested atypical ductal hyperplasia or a radial scar or did not agree with the mammographic appearance of the lesion. At biopsy, a radiologist rated the type of mammographic abnormalities and assigned a Breast Imaging and Reporting System (BIRAD) category of 4 or 5; category 4 lesions were subdivided into 4 subcategories according to mammographic appearance to better estimate breast cancer risk. A decision analytic model was then constructed to compare the costs of the 2 approaches. The influence of procedural costs on outcomes was modeled by Monte Carlo simulations.
Findings.—Compared with lesions diagnosed by surgical excisional biopsy, lesions diagnosed by stereotactic core biopsy were less likely to be masses (39% vs 55%), to be classified as highly suspicious for cancer (17% vs 26%), and to treated with single procedure (74% vs 81%) (P < 0.001 for each). Of the lesions diagnosed as cancer, those diagnosed by surgical excisional biopsy were less likely to be treated with a 1-stage surgical procedure (33% vs 84%) (P < 0.001) and were associated with higher total costs regardless of whether the treatment was mastectomy ($2,775 vs $1,849) or lumpectomy ($2,112 vs $1,365). In sensitivity analyses, stereotactic core biopsy was optimal in 95% of the simulations. Stereotactic core biopsy was favored for lesions at low suspicion of being cancer, for calcifications, for masses, and, overall, for patients who were treated with lumpectomy only. Conclusions.—Stereotactic core biopsy was less costly than surgical excisional biopsy for identifying mammographically detected breast lesions, particularly when the lesions were at low
Cost Minimization Study of Image-Guided Core Biopsy Versus Surgical Excisional Biopsy for Women With Abnormal Mammograms Golub RM, Bennet CL, Stinson T, et al (Lynn Sage Comprehensive Breast Ctr, Chicago; Northwestern Univ, Chicago; VA Midwest Ctr for Health Services and Policy Research, Chicago; et al) J Clin Oncol 22:2430-2437, 2004
Background.—Stereotactic core biopsy is generally less invasive and less expensive than surgical excisional biopsy for evaluating nonpalpable mammographic lesions. However, this may not be true for lesions considered likely to be cancer or that are likely to be missed by stereotactic core biopsy. The purpose of this study was to prospectively assess lesions detected through mammography, the potential surgical course, and the related costs, and to use these observational data to perform a cost-minimization study of the 2 biopsy alternatives, considering
94 94
®
Breast Diseases: A Year Book Quarterly Vol 16 No 1 2005
See the expert perspective by Grunfeld earlier in this issue.
suspicion of being cancer or when calcifications or masses were suspected. In these latter cases, using stereotactic core biopsy as the preferred approach could significantly influence cost savings. What has been intuitive to many in this field regarding the costs of core biopsy vs excisional biopsy has been verified here with objective data. Moreover, the patients were seen and the data gathered between 1996 and 1998; improvements in the speed and accuracy of image-guided needle biopsy techniques since that time suggest that such data, if collected today, would likely be even more impressive. The diagnostic accuracy of the now commonly used technique of imageguided vacuum-assisted core biopsy is now at a level comparable to that of surgical excisional biopsy.1,2 Further, the practice during image-guided nee-
1–52
The Relationship Among Physicians’ Specialty, Perceptions of the Risks and Benefits of Adjuvant Tamoxifen Therapy, and Its Recommendation in Older Patients With Breast Cancer Malek K, Fink AK, Thwin SS, et al (Boston Univ; Fallon Healthcare System, Worcester, Mass; Univ of Massachusetts, Worcester; et al) Med Care 42:700-706, 2004
Background.—Five years of adjuvant therapy with tamoxifen is recommended for all postmenopausal women with estrogen receptor–positive breast cancer, except for those patients at high risk of thromboembolic disease. This rec-
dle biopsy of lesions (particularly small ones) of leaving metallic clips in place after the biopsy makes subsequent localization of the lesion at surgery rapid and highly accurate. When malignant lesions are diagnosed with image-guided needle biopsy, subsequent staging, with verification of additional lesions and nodal status, can be performed with additional image-guided biopsies, ensuring that the final surgical procedure will be done with full knowledge of the extent of the lesion or lesions as well as the nodal status. Another topic to be considered with regard to initial biopsy and staging by means of percutaneous biopsy is that neoadjuvant chemotherapy is increasingly being used for patients with large tumors to enhance the ultimate outcome. This initial, presurgical therapy can therefore be begun with full knowledge
and histologic proof of tumor grade, receptor status, nodal status, and extent of disease, with metallic tumor marker placement if necessary, done entirely with percutaneous intervention. This represents a major improvement in breast cancer management.
ommendation is based on evidence from clinical trials indicating that tamoxifen is associated with a 40% reduction in the risks of recurrence and distant metastasis and a 47% reduction in the risk of developing a contralateral breast cancer. Additional potential benefits from tamoxifen therapy include improved bone mineral density, reduced incidence of bone fractures, and reduced levels of total cholesterol and low-density lipoprotein cholesterol. However, these potential benefits are balanced by numerous side effects, including symptoms of hormone deprivation and increased risk of uterine cancer, thromboembolic disease, cerebrovascular accidents, and cataracts. Previous studies have found that demographic factors, tumor characteristics, comorbid conditions, risk communication, and patient knowledge all affect physicians’ recommendations for or against tamoxifen treatment.
The purpose of the present study was to determine whether tamoxifen recommendations differ according to physician specialty (surgery vs medical oncology) and to identify the physicians’ perceptions of the risks and benefits of tamoxifen. Methods.—Subjects were women aged 65 years or more from geographically diverse areas with stage I-IIIa breast cancer who had been enrolled in a prospective cohort study. Data were obtained from the patients via telephone 3 months after definitive breast surgery and from their medical records. The patients’ surgeons and medical oncologists were recruited to provide patient-specific information about their perceptions of the risks and benefits of tamoxifen and whether they recommended use of tamoxifen for that patient. Each physician also completed a questionnaire regarding
P. J. Dempsey, MD
References 1. Liberman L, Gougoutas CA, Zakowski MF, et al: Calcifications highly suggestive of malignancy: Comparison of breast biopsy methods. AJR Am J Roentgenol 177:165-172, 2001. 2. Pfarl G, Helbich T, Riedl CC, et al: Stereotactic 11-gauge vacuum-assisted breast biopsy: A validation study. AJR Am J Roentgenol 179:1503-1507, 2002.
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Breast Diseases: A Year Book Quarterly Vol 16 No 1 2005
95 95
score was better than that of the patients, and mean scores on mental functioning were similar between the 2 groups. Similar proportions of caregivers and patients were depressed (11% and 12%) at that time, but significantly more caregivers than patients were anxious (35% vs 19%, P = 0.009). By the start of the terminal phase, the proportion of caregivers who were depressed had increased to 30% vs 9%, P < 0.02) and the perceivedburden score had risen from that at the beginning of the palliative period. This burden, scored by the Zarit Burden Inventory, was the most important predictor of both anxiety and depression. Among employed caregivers, 69% reported some form of adverse impact on work, and 77%
reported missing work because of caregiving responsibilities during the terminal period. Prescription drugs were the most significant component of the financial burden. Conclusions.—Caregivers experienced increases in depression and perceived burden as patients’ functional status declined. Strategies are needed to help reduce the psychosocial, occupational, and economic burden associated with caregiving.
1–51
all downstream costs from the time of biopsy through definitive surgical treatment. Methods.—Clinical and cost data were collected for all 1,121 patients who underwent stereotactic core biopsy and all 501 patients who underwent surgical excisional biopsy at the authors’ institution between 1996 and 1998. Stereotactic core biopsy was performed for calcified lesions and for architectural distortions; surgical excisional biopsy was used when the core biopsy findings suggested atypical ductal hyperplasia or a radial scar or did not agree with the mammographic appearance of the lesion. At biopsy, a radiologist rated the type of mammographic abnormalities and assigned a Breast Imaging and Reporting System (BIRAD) category of 4 or 5; category 4 lesions were subdivided into 4 subcategories according to mammographic appearance to better estimate breast cancer risk. A decision analytic model was then constructed to compare the costs of the 2 approaches. The influence of procedural costs on outcomes was modeled by Monte Carlo simulations.
Findings.—Compared with lesions diagnosed by surgical excisional biopsy, lesions diagnosed by stereotactic core biopsy were less likely to be masses (39% vs 55%), to be classified as highly suspicious for cancer (17% vs 26%), and to treated with single procedure (74% vs 81%) (P < 0.001 for each). Of the lesions diagnosed as cancer, those diagnosed by surgical excisional biopsy were less likely to be treated with a 1-stage surgical procedure (33% vs 84%) (P < 0.001) and were associated with higher total costs regardless of whether the treatment was mastectomy ($2,775 vs $1,849) or lumpectomy ($2,112 vs $1,365). In sensitivity analyses, stereotactic core biopsy was optimal in 95% of the simulations. Stereotactic core biopsy was favored for lesions at low suspicion of being cancer, for calcifications, for masses, and, overall, for patients who were treated with lumpectomy only. Conclusions.—Stereotactic core biopsy was less costly than surgical excisional biopsy for identifying mammographically detected breast lesions, particularly when the lesions were at low
Cost Minimization Study of Image-Guided Core Biopsy Versus Surgical Excisional Biopsy for Women With Abnormal Mammograms Golub RM, Bennet CL, Stinson T, et al (Lynn Sage Comprehensive Breast Ctr, Chicago; Northwestern Univ, Chicago; VA Midwest Ctr for Health Services and Policy Research, Chicago; et al) J Clin Oncol 22:2430-2437, 2004
Background.—Stereotactic core biopsy is generally less invasive and less expensive than surgical excisional biopsy for evaluating nonpalpable mammographic lesions. However, this may not be true for lesions considered likely to be cancer or that are likely to be missed by stereotactic core biopsy. The purpose of this study was to prospectively assess lesions detected through mammography, the potential surgical course, and the related costs, and to use these observational data to perform a cost-minimization study of the 2 biopsy alternatives, considering
94 94
®
Breast Diseases: A Year Book Quarterly Vol 16 No 1 2005
See the expert perspective by Grunfeld earlier in this issue.
suspicion of being cancer or when calcifications or masses were suspected. In these latter cases, using stereotactic core biopsy as the preferred approach could significantly influence cost savings. What has been intuitive to many in this field regarding the costs of core biopsy vs excisional biopsy has been verified here with objective data. Moreover, the patients were seen and the data gathered between 1996 and 1998; improvements in the speed and accuracy of image-guided needle biopsy techniques since that time suggest that such data, if collected today, would likely be even more impressive. The diagnostic accuracy of the now commonly used technique of imageguided vacuum-assisted core biopsy is now at a level comparable to that of surgical excisional biopsy.1,2 Further, the practice during image-guided nee-
1–52
The Relationship Among Physicians’ Specialty, Perceptions of the Risks and Benefits of Adjuvant Tamoxifen Therapy, and Its Recommendation in Older Patients With Breast Cancer Malek K, Fink AK, Thwin SS, et al (Boston Univ; Fallon Healthcare System, Worcester, Mass; Univ of Massachusetts, Worcester; et al) Med Care 42:700-706, 2004
Background.—Five years of adjuvant therapy with tamoxifen is recommended for all postmenopausal women with estrogen receptor–positive breast cancer, except for those patients at high risk of thromboembolic disease. This rec-
dle biopsy of lesions (particularly small ones) of leaving metallic clips in place after the biopsy makes subsequent localization of the lesion at surgery rapid and highly accurate. When malignant lesions are diagnosed with image-guided needle biopsy, subsequent staging, with verification of additional lesions and nodal status, can be performed with additional image-guided biopsies, ensuring that the final surgical procedure will be done with full knowledge of the extent of the lesion or lesions as well as the nodal status. Another topic to be considered with regard to initial biopsy and staging by means of percutaneous biopsy is that neoadjuvant chemotherapy is increasingly being used for patients with large tumors to enhance the ultimate outcome. This initial, presurgical therapy can therefore be begun with full knowledge
and histologic proof of tumor grade, receptor status, nodal status, and extent of disease, with metallic tumor marker placement if necessary, done entirely with percutaneous intervention. This represents a major improvement in breast cancer management.
ommendation is based on evidence from clinical trials indicating that tamoxifen is associated with a 40% reduction in the risks of recurrence and distant metastasis and a 47% reduction in the risk of developing a contralateral breast cancer. Additional potential benefits from tamoxifen therapy include improved bone mineral density, reduced incidence of bone fractures, and reduced levels of total cholesterol and low-density lipoprotein cholesterol. However, these potential benefits are balanced by numerous side effects, including symptoms of hormone deprivation and increased risk of uterine cancer, thromboembolic disease, cerebrovascular accidents, and cataracts. Previous studies have found that demographic factors, tumor characteristics, comorbid conditions, risk communication, and patient knowledge all affect physicians’ recommendations for or against tamoxifen treatment.
The purpose of the present study was to determine whether tamoxifen recommendations differ according to physician specialty (surgery vs medical oncology) and to identify the physicians’ perceptions of the risks and benefits of tamoxifen. Methods.—Subjects were women aged 65 years or more from geographically diverse areas with stage I-IIIa breast cancer who had been enrolled in a prospective cohort study. Data were obtained from the patients via telephone 3 months after definitive breast surgery and from their medical records. The patients’ surgeons and medical oncologists were recruited to provide patient-specific information about their perceptions of the risks and benefits of tamoxifen and whether they recommended use of tamoxifen for that patient. Each physician also completed a questionnaire regarding
P. J. Dempsey, MD
References 1. Liberman L, Gougoutas CA, Zakowski MF, et al: Calcifications highly suggestive of malignancy: Comparison of breast biopsy methods. AJR Am J Roentgenol 177:165-172, 2001. 2. Pfarl G, Helbich T, Riedl CC, et al: Stereotactic 11-gauge vacuum-assisted breast biopsy: A validation study. AJR Am J Roentgenol 179:1503-1507, 2002.
®
Breast Diseases: A Year Book Quarterly Vol 16 No 1 2005
95 95