Tamoxifen for breast cancer risk reduction: impact of alternative approaches to quality-of-life adjustment on cost-effectiveness analysis

Joy Melnikow, Stephen Birch, Christina Slee, Theodore J McCarthy, L Jay Helms, Miriam Kuppermann

    Research output: Contribution to journalArticlepeer-review

    Abstract

    BACKGROUND: In cost-effectiveness analysis (CEA), the effects of health-care interventions on multiple health dimensions typically require consideration of both quantity and quality of life.

    OBJECTIVES: To explore the impact of alternative approaches to quality-of-life adjustment using patient preferences (utilities) on the outcome of a CEA on use of tamoxifen for breast cancer risk reduction.

    RESEARCH DESIGN: A state transition Markov model tracked hypothetical cohorts of women who did or did not take 5 years of tamoxifen for breast cancer risk reduction. Incremental quality-adjusted effectiveness and cost-effectiveness ratios (ICERs) for models including and excluding a utility adjustment for menopausal symptoms were compared with each other and to a global utility model.

    SUBJECTS: Two hundred fifty-five women aged 50 and over with estimated 5-year breast cancer risk >or=1.67% participated in utility assessment interviews.

    MEASURES: Standard gamble utilities were assessed for specified tamoxifen-related health outcomes, current health, and for a global assessment of possible outcomes of tamoxifen use.

    RESULTS: Inclusion of a utility for menopausal symptoms in the outcome-specific models substantially increased the ICER; at the threshold 5-year breast cancer risk of 1.67%, tamoxifen was dominated. When a global utility for tamoxifen was used in place of outcome-specific utilities, tamoxifen was dominated under all circumstances.

    CONCLUSIONS: CEAs may be profoundly affected by the types of outcomes considered for quality-of-life adjustment and how these outcomes are grouped for utility assessment. Comparisons of ICERs across analyses must consider effects of different approaches to using utilities for quality-of-life adjustment.

    Original languageEnglish
    Pages (from-to)946-953
    Number of pages8
    JournalMedical care
    Volume46
    Issue number9
    DOIs
    Publication statusPublished - Sep 2008

    Keywords

    • Antineoplastic Agents, Hormonal/adverse effects
    • Breast Neoplasms/economics
    • California
    • Cohort Studies
    • Cost-Benefit Analysis/statistics & numerical data
    • Decision Making
    • Female
    • Humans
    • Markov Chains
    • Middle Aged
    • Outcome Assessment (Health Care)/statistics & numerical data
    • Quality of Life
    • Quality-Adjusted Life Years
    • Risk Reduction Behavior
    • Tamoxifen/adverse effects

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