Decision analysis of tamoxifen for the prevention of invasive breast cancer.
OBJECTIVE
The recent Breast Cancer Prevention Trial has shown that tamoxifen may prevent invasive breast cancer. We used a Markov model to estimate the long-term effects of chemoprevention with tamoxifen on survival, quality-adjusted survival, and health care costs.


METHODS
We used a hypothetical cohort of women with breast-cancer risk similar to that of participants in the Breast Cancer Prevention Trial, and a computer-based decision analysis (Markov model and 500 Monte Carlo simulations) to model the outcomes of interest. Survival calculations were from Surveillance, Epidemiology, and End-Results (SEER) data; preference ratings from a time trade-off questionnaire administered to a group of average-risk women; and cost estimates from the Group Health Cooperative of Puget Sound and the Health Care Financing Administration. We obtained utility measures for quality-adjustment by administering a time trade-off questionnaire to a group of community-based women.


RESULTS
Use of tamoxifen prolonged the average survival of cohort members by 69 days (95% probability interval [PI] 27 to 117) for those who started use at age 35 years; 40 days (95% PI 16 to 67) for those who started use at age 50 years; and 27 days (95% PI 14 to 40) for those who started use at age 60 years. Tamoxifen extended quality-adjusted survival by 38 days (95% PI 0.1 to 82) at age 35, 25 days (95% PI 0 to 50) at age 50, and 22 days (95% PI 5 to 39) days at age 60. Chemoprevention with tamoxifen cost $46,619 (95% PI $27,928 to $98,796) per life year life saved for women who started at age 35; for women over age 50, it cost more than $50,000 per life year saved.


CONCLUSIONS
Tamoxifen use may improve long-term survival and quality-adjusted survival among women who are at increased risk of breast cancer, but this benefit diminishes with age. Tamoxifen is cost-effective in comparison with other cancer treatment strategies for younger women only.
Grann
V R
VR
Herbert Irving Comprehensive Cancer Center, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
Sundararajan
V
V
Jacobson
J S
JS
Whang
W
W
Heitjan
D F
DF
Antman
K H
KH
Neugut
A I
AI
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000191:economics / Q000401:mortality / Q000517:prevention & control* / Q000523:psychology; D018890:Chemoprevention / Q000191:economics; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008390:Markov Chains; D008875:Middle Aged; D008962:Models, Theoretical; D009010:Monte Carlo Method; D010919:Placebos; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D012680:Sensitivity and Specificity; D011795:Surveys and Questionnaires; D013629:Tamoxifen / Q000494:pharmacology* / Q000627:therapeutic use*; D013997:Time Factors
D010919:Placebos; D013629:Tamoxifen