title: Cost effectiveness of fracture prevention in postmenopausal women who receive aromatase inhibitors for early breast cancer.
abstract: OBJECTIVE
  Aromatase inhibitors (AIs) increase the risk of osteoporosis and related fractures in postmenopausal women who receive adjuvant AIs for hormone receptor (HR) -positive early breast cancer (EBC). We compared the cost effectiveness of alternative screening and treatment strategies for fracture prevention.
  
  
  METHODS
  We developed a Markov state transition model to simulate clinical practice and outcomes in a hypothetical cohort of women age 60 years with HR-positive EBC starting a 5-year course of AI therapy after primary surgery for breast cancer. Outcomes were quality-adjusted life-years (QALYs), lifetime cost, and incremental cost-effectiveness ratio (ICER). We compared the following strategies: no intervention; one-time bone mineral density (BMD) screening and selective bisphosphonate therapy in women with osteoporosis or osteopenia; annual BMD screening and selective bisphosphonate therapy in women with osteoporosis or osteopenia; and universal bisphosphonate therapy.
  
  
  RESULTS
  ICERs for annual BMD screening followed by oral bisphosphonates for those with osteoporosis, annual BMD screening followed by oral bisphosphonates for those with osteopenia, and universal treatment with oral bisphosphonates were $87,300, $129,300, and $283,600 per QALY gained, respectively. One-time BMD screening followed by oral bisphosphonates for those with osteoporosis or osteopenia was dominated. Our results were sensitive to age at the initiation of AI therapy, type of bisphosphonates, post-treatment residual effect of bisphosphonates, and a potential adjuvant benefit of intravenous bisphosphonates.
  
  
  CONCLUSIONS
  In postmenopausal women receiving adjuvant AIs for HR-positive EBC, a policy of baseline and annual BMD screening followed by selective treatment with oral bisphosphonates for those diagnosed with osteoporosis is a cost-effective use of societal resources.
authors.affiliation: Brigham and Women’sHospital, Boston, MA, USA. kito5@partners.org
authors.forename: Kouta
authors.initials: K
authors.lastname: Ito
authors.forename: Victoria S
authors.initials: VS
authors.lastname: Blinder
authors.forename: Elena B
authors.initials: EB
authors.lastname: Elkin
mesh_terms: D015502:Absorptiometry, Photon / Q000191:economics*; D000284:Administration, Oral; D000367:Age Factors; D047072:Aromatase Inhibitors / Q000009:adverse effects*; D015519:Bone Density / Q000187:drug effects; D050071:Bone Density Conservation Agents / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use*; D001851:Bone Diseases, Metabolic / Q000139:chemically induced / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000191:economics; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000191:economics / Q000201:enzymology / Q000401:mortality / Q000473:pathology; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D004164:Diphosphonates / Q000008:administration & dosage / Q000191:economics* / Q000627:therapeutic use*; D018572:Disease-Free Survival; D016527:Drug Costs; D055088:Early Detection of Cancer; D005260:Female; D050723:Fractures, Bone / Q000139:chemically induced / Q000000981:diagnostic imaging / Q000191:economics* / Q000517:prevention & control*; D006801:Humans; D008390:Markov Chains; D008875:Middle Aged; D018803:Models, Economic; D009367:Neoplasm Staging; D010024:Osteoporosis / Q000139:chemically induced / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000191:economics; D017698:Postmenopause; D011237:Predictive Value of Tests; D019057:Quality-Adjusted Life Years; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D047072:Aromatase Inhibitors; D050071:Bone Density Conservation Agents; D004164:Diphosphonates