title: Cancer Care Coordinators to Improve Tamoxifen Persistence in Breast Cancer: How Heterogeneity in Baseline Prognosis Impacts on Cost-Effectiveness.
abstract: OBJECTIVE
  To assess the cost-effectiveness of a cancer care coordinator (CCC) in helping women with estrogen receptor positive (ER+) early breast cancer persist with tamoxifen for 5 years.
  
  
  METHODS
  We investigated the cost-effectiveness of a CCC across eight breast cancer subtypes, defined by progesterone receptor (PR) status, human epidermal growth factor receptor 2 (HER2) status, and local/regional spread. These subtypes range from excellent to poorer prognoses. The CCC helped in improving tamoxifen persistence by providing information, checking-in by phone, and "troubleshooting" concerns. We constructed a Markov macrosimulation model to estimate health gain (in quality-adjusted life-years or QALYs) and health system costs in New Zealand, compared with no CCC. Participants were modeled until death or till the age of 110 years. Some input parameters (e.g., the impact of a CCC on tamoxifen persistence) had sparse evidence. Therefore, we used estimates with generous uncertainty and conducted sensitivity analyses.
  
  
  RESULTS
  The cost-effectiveness of a CCC for regional ER+/PR-/HER2+ breast cancer (worst prognosis) was NZ $23,400 (US $15,800) per QALY gained, compared with NZ $368,500 (US $248,800) for local ER+/PR+/HER2- breast cancer (best prognosis). Using a cost-effectiveness threshold of NZ $45,000 (US $30,400) per QALY, a CCC would be cost-effective only in the four subtypes with the worst prognoses.
  
  
  CONCLUSIONS
  There is value in investigating cost-effectiveness by different subtypes within a disease. In this example of breast cancer, the poorer the prognosis, the greater the health gains from a CCC and the better the cost-effectiveness. Incorporating heterogeneity in a cost-utility analysis is important and can inform resource allocation decisions. It is also feasible to undertake in practice.
authors.affiliation: Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme, Department of Public Health, University of Otago Wellington, Wellington, New Zealand. Electronic address: nisha.nair@otago.ac.nz.
authors.forename: Nisha
authors.initials: N
authors.lastname: Nair
authors.affiliation: Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme, Department of Public Health, University of Otago Wellington, Wellington, New Zealand.
authors.forename: Giorgi
authors.initials: G
authors.lastname: Kvizhinadze
authors.affiliation: Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme, Department of Public Health, University of Otago Wellington, Wellington, New Zealand.
authors.forename: Tony
authors.initials: T
authors.lastname: Blakely
mesh_terms: D018931:Antineoplastic Agents, Hormonal / Q000627:therapeutic use*; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology*; D003362:Cost-Benefit Analysis; D005260:Female; D005102:Health Expenditures; D006801:Humans; D008390:Markov Chains; D055118:Medication Adherence; D017059:Models, Econometric; D009362:Neoplasm Metastasis; D009520:New Zealand; D062526:Patient Navigation / Q000191:economics*; D011379:Prognosis; D019057:Quality-Adjusted Life Years; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000096:biosynthesis; D011980:Receptors, Progesterone / Q000096:biosynthesis; D013629:Tamoxifen / Q000627:therapeutic use*
chemical_list: D018931:Antineoplastic Agents, Hormonal; D018719:Erb-b2 Receptor Tyrosine Kinases; D011980:Receptors, Progesterone; D013629:Tamoxifen
keywords: breast cancer; care coordinators; compliance; cost-effectiveness; heterogeneity; patient navigators; persistence; tamoxifen