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  • br All costs were normalized to US dollars br To

    2020-08-12


    All costs were normalized to 2017 US dollars.
    To compute QALYs, we obtained from the literature health utilities associated with the negative effects of breast cancer treatments (i.e., surgery, radiation, chemotherapy, and hor-monal therapy) and utilities for terminal disease with breast cancer versus other diseases as causes of death (Table 1) [51,52]. These utility values were weighted against their respective durations in which the treatment or disease stage applied to calculate QALYs.
    We performed deterministic and probabilistic CEAs. Our simulation for deterministic CEA was based on a birth cohort of 2 million women. To address model uncertainties, we ran 100 rep-etitions of the simulation model with a cohort size of 100,000 women, recorded mean costs and QALYs, and constructed the net benefit of each strategy, defined as (societal willingness to pay QALY) cost. For deterministic CEA, we obtained the mean costs and QALYs for the simulated cohort of 2 million women, ranked the strategies by costs in ascending order, removed strategies that 104778-14-5 were dominated or extendedly dominated, and calculated the incremental cost-effectiveness ratios (ICERs) using the remaining strategies [53]. For probabilistic analysis, we calculated the prob-ability of each strategy being the strategy with the highest ex-pected net benefit corresponding to various levels of societal willingness to pay (e.g., $50,000/QALY or $100,000/QALY). We present findings of the probabilistic analysis in the cost-effectiveness acceptability (CEacc) frontier [53,54], which depicts the probability that the strategy with the highest net benefit is cost-effective (i.e., optimal) in corresponding to a specific level of societal willingness to pay.
    This study received exemption from the Institutional Review Board at The University of Texas MD Anderson Cancer Center.
    Results
    Deterministic CEA
    Table 3 presents the pairwise comparison of the CEA findings and summarizes the mean cost increase and QALY gain associated with each screening strategy compared with no screening. On average, screening increased the lifetime costs (discounted at 3%) for women at an average risk of developing breast cancer, ranging from $642 per person for biennial screening between the ages of 50 and 75 years to $2149 per person for annual mammography screening starting at the age of 40 years, without an upper age limit. The screening strategy pyloric sphincter yielded the largest gain in QALYs was annual screening between ages 40 and 75 years, pro-ducing a QALY (also discounted at 3%) gain of 0.0340 per person (z12.4 days) compared with no screening.
    Results of stepwise comparisons from the deterministic CEA are illustrated in a cost-effectiveness plane (Fig. 2). After excluding strategies that were dominated or extendedly dominated, four strategies remained on the cost-effectiveness efficiency frontier: no screening, biennial screening 50e75, annual screening 45e54 followed by biennial screening 55e75, and annual screening 40e75; the latter three strategies represent the updated USPSTF/ AAFP/ACP, updated ACS, and ACOG/ACR guidelines, respectively. The screening strategy that starts annual mammography at age 45 years and switches to biennial screening between ages 55 and 75 years was the most cost-effective. Compared with the updated USPSTF/AAFP/ACP guidelines with a cessation age of 75 years, the ICER of screening based on the updated ACS guideline was $40,135/QALY, which was below the range of the cost-effectiveness threshold ($50,000e$100,000/QALY) commonly cited in US-based cost-effectiveness studies.
    Treatment pattern Stage 0 Stage I
    Stage II
    Stage III
    Stage IV
    Age Age
    Age Age
    Age Age
    Age Age
    Age Age
    no surgery
    lumpectomy
    mastectomy
    surgery
    lumpectomy
    mastectomy
    surgery
    lumpectomy
    mastectomy
    surgery
    lumpectomy
    mastectomy
    Cost related to breast cancer treatment, by care phase
    Initial care phase
    No chemotherapy, no RT,
    no surgery
    lumpectomy
    mastectomy
    surgery
    lumpectomy
    mastectomy
    surgery
    lumpectomy
    mastectomy
    surgery
    lumpectomy
    mastectomy
    Continuing care phase
    Year 6þ
    continued on next page
    Table 2 – continued
    Treatment pattern Stage 0
    Stage I
    Stage II
    Stage III Stage IV
    Age Age
    Age Age
    Age Age
    Age Age Age Age
    Terminal care phase
    cancer
    Note. Initial care was defined as care incurred within the first 12 mo of diagnosis, terminal care reflected the last 12 mo of life, and continuingcare captured everything that happens between initial and terminal care phases [45].