title: Prognostic imaging in neoadjuvant chemotherapy of locally-advanced breast cancer should be cost-effective.
abstract: BACKGROUND
  The use of neoadjuvant chemotherapy in cases of locally advanced breast cancer has been steadily increasing, and is also in wider use for other cancers. As a consequence, a growing number of studies have focused on the question of how best to assess the therapeutic response to various chemotherapy or systemic therapy regimens. Prognostic imaging of response to therapy early in the course of a planned chemotherapy regimen could be of considerable value, particularly if shifting to another therapy regimen would be more effective.
  
  
  METHODS
  A cost effectiveness analysis was completed, specific to imaging of neoadjuvant chemotherapy response in breast cancer, to determine the dominant parameters that would make imaging systems cost effective. The cost analysis was completed with respect to a system for near infrared spectral imaging, but the costs are not dramatically different for other systems such as PET or MRI. Using a standard metric of $25,000 per discounted life year gained as a measure of a successful system.
  
  
  RESULTS
  It is shown that system specificity and patient average life expectancy are not dominant factors. Increases in cure rate and the efficacy of the initial chemotherapy are dominant factors. As long as the initial chemotherapy was less than 90% effective, most imaging systems would be cost effective, and if the cure rate of the disease could be increased as little as 1% through a change to alternate therapy, then the cost effectiveness of the system would be acceptable.
  
  
  CONCLUSIONS
  Based upon this simple economic analysis, diagnostic imaging of neoadjuvant chemotherapy appears warranted, assuming that it can be shown that the early shift from ineffective neoadjuvant chemotherapy to a more effective one has a measurable benefit in cure rate. This study indicates that the most important issue is to assess the added benefit of individualized chemotherapy in patient management, and clinical trials in this area would then provide the data required to justify analysis of prognostic imaging procedures.
authors.affiliation: Amos Tuck School of Business, Dartmouth College, Hanover, NH 03755, USA.
authors.forename: Marc
authors.initials: M
authors.lastname: Schegerin
authors.forename: Anna N A
authors.initials: AN
authors.lastname: Tosteson
authors.forename: Peter A
authors.initials: PA
authors.lastname: Kaufman
authors.forename: Keith D
authors.initials: KD
authors.lastname: Paulsen
authors.forename: Brian W
authors.initials: BW
authors.lastname: Pogue
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000188:drug therapy* / Q000191:economics; D017024:Chemotherapy, Adjuvant / Q000191:economics*; D003362:Cost-Benefit Analysis / Q000191:economics*; D003952:Diagnostic Imaging / Q000191:economics* / Q000379:methods; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000191:economics*; D011237:Predictive Value of Tests; D011379:Prognosis; D012680:Sensitivity and Specificity; D013055:Spectrophotometry, Infrared / Q000191:economics