Medical Care

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Medical Care:
doi: 10.1097/MLR.0b013e318179250f
Original Article

Tamoxifen for Breast Cancer Risk Reduction: Impact of Alternative Approaches to Quality-of-Life Adjustment on Cost-Effectiveness Analysis

Melnikow, Joy MD, MPH*; Birch, Stephen DPhil†; Slee, Christina MPH‡; McCarthy, Theodore J. MA§; Helms, L Jay PhD§; Kuppermann, Miriam PhD, MPH¶

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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 ≥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.

© 2008 Lippincott Williams & Wilkins, Inc.


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