title: Cost-effectiveness analysis of whole-mount pathology processing for patients with early breast cancer undergoing breast conservation.
abstract: BACKGROUND
  Obtaining accurate histopathologic detail for breast lumpectomy specimens is challenging because of sampling and loss of three-dimensional conformational features with conventional processing. The whole-mount (wm) technique is a novel method of serial pathologic sectioning designed to optimize cross-sectional visualization of resected specimens and determination of margin status.
  
  
  METHODS
  Using a Markov chain cohort simulation cost-effectiveness model, we compared conventional processing with wm technique for breast lumpectomies. Cost-effectiveness was evaluated from the perspective of the Canadian health care system and compared using incremental cost-effectiveness ratios (icers) for cost per quality-adjusted life-year (qaly) over a 10-year time horizon. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the model with willingness-to-pay (wtp) thresholds of $0-$100,000. Costs are reported in adjusted 2014 Canadian dollars, discounted at a rate of 3%.
  
  
  RESULTS
  Compared with conventional processing, wm processing is more costly ($19,989 vs. $18,427) but generates 0.03 more qalys over 10 years. The icer is $45,414, indicating that this additional amount is required for each additional qaly obtained. The model was robust to all variance in parameters, with the prevalence of positive margins accounting for most of the model's variability.
  
  
  CONCLUSIONS
  After a wtp threshold of $45,414, wm processing becomes cost-effective and ultimately generates fewer recurrences and marginally more qalys over time. Excellent baseline outcomes for the current treatment of breast cancer mean that incremental differences in survival are small. However, the overall benefit of the wm technique should be considered in the context of achieving improved accuracy and not just enhancements in clinical effectiveness.
authors.affiliation: Division of Surgical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON;; Department of Surgery, University of Toronto, Toronto, ON;
authors.forename: N J Look
authors.initials: NJ
authors.lastname: Hong
authors.affiliation: Sunnybrook Research Institute, Toronto, ON.
authors.forename: G M
authors.initials: GM
authors.lastname: Clarke
authors.affiliation: Sunnybrook Research Institute, Toronto, ON.
authors.forename: M J
authors.initials: MJ
authors.lastname: Yaffe
authors.affiliation: Division of Surgical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON;; Department of Surgery, University of Toronto, Toronto, ON;
authors.forename: C M B
authors.initials: CM
authors.lastname: Holloway
keywords: Breast cancer; cost-effectiveness; pathology