Choosing wisely.

Top Line: What is the most cost-effective adjuvant treatment for ductal carcinoma in situ (DCIS)?

The Study: It is debated whether DCIS is “overtreated.” And radiation seems to always be first on the chopping block when considering ways to de-escalate therapy. This study puts the benefits of various adjuvant therapies in the context of their quality of life effects and cost. A Markov model was used to simulate 6 treatment approaches following lumpectomy: observation, tamoxifen alone, aromatase inhibitor (AI) alone, RT alone, tam + RT, or AI + RT. Of note, the model used clinical trial endocrine therapy compliance levels (70% completing 5 years), which may be higher than real-world compliance. Another note is that hypofractionation was used for RT cost analysis. Clinical trials and meta-analyses were used to estimate recurrence risks and adverse effects for the various treatment approaches. Lastly, salvage treatment was also modeled and factored into the analysis. For standard risk DCIS, RT alone was the most cost effective treatment with the greatest net monetary benefit. For good-risk DCIS, observation alone was most cost effective. All other treatment strategies cost more while providing fewer quality adjusted life years (QALY). Surprisingly, any approach that included endocrine therapy had fewer QALYs than observation--regardless of risk and age. Why? “The trade-off between efficacy and side-effects is not favorable for hormonal treatment.” 

TBL: Radiation and observation may be more cost-effective treatments than endocrine therapy-based approaches for standard and good-risk DCIS. | Gupta, J Clin Oncol 2021

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