Ten‐Year Survival and Cost Following Breast Cancer Recurrence: Estimates from SEER‐Medicare Data

Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
Value in Health (Impact Factor: 3.28). 02/2008; 11(2):213 - 220. DOI: 10.1111/j.1524-4733.2007.00226.x


A variety of pharmacologic therapies are available or in development for the prevention of breast cancer recurrence. Assessing the value of these treatments is compromised by a paucity of data on the impact of recurrence on economic costs and survival. The purpose of this study was to shed light on these issues.

We conducted a retrospective analysis of linked SEER-Medicare data. All patients in the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) registry who were diagnosed with nonmetastatic breast cancer during 1991-1993 were identified, and their subsequent Medicare claims were scanned for evidence of further breast cancer events (local or distant recurrence, contralateral breast cancer). Medicare claims were then scanned from the time of the event through 2002 to assess patterns of survival and costs.

We identified 10,798 patients in SEER who were diagnosed with nonmetastatic breast cancer during 1991-1993, including 1833 who subsequently had another breast cancer event (local recurrence, 958; distant recurrence, 622; contralateral breast cancer, 253). Median survival was 37 months and 8 months among patients with local and distant recurrence, respectively; 53% of patients with contralateral breast cancer remained alive after all the data were censored at 97 months. Expected 10-year costs (2004 US$, discounted 3%) attributable to distant recurrence, local recurrence, and contralateral breast cancer were $11,450 (SE 2056), $19,596 (SE 1754), and $19,183 (SE 4131), respectively.

Breast cancer recurrence and contralateral breast cancer lead to substantial increases in costs, amounting to approximately $11,000-19,000 over 10 years depending on type. The impact of these events on survival also varies considerably by type.

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    • "Papers that do report survival by ER status seem to report a wide range of estimates. A recent systematic literature review by Boswell and colleagues [9] identified only one study during 2000-2011 that evaluated burden of disease based on ER status [13]. This study by Stokes et al. found that elderly women diagnosed with Stage I-III ER + breast cancer who, using a claims-based algorithm, appeared to have a distant recurrence survived a median of 9 months following recurrence [13]. "
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    ABSTRACT: Background Few studies have evaluated survival, treatment, resource use, and costs among women with stage IV ER + breast cancer (BC) who did not receive HER2 targeted therapy. Methods Using linked Surveillance, Epidemiology, and End Results (SEER) and Medicare data from 2006-2009, women aged 66+ years with an incident diagnosis of stage IV ER + BC (index date) in 2007 and no HER2 targeted therapy were identified. A comparison cohort without cancer was created from the SEER 5% Medicare sample and matched 1:1 to the study cohort based on age, sex, and race. All patients had continuous enrollment for a 12-month baseline period prior to index and were followed until the end of the study window, disenrollment, or death, whichever came first. Resource utilization and costs (by place of service, reported per patient per month, PPPM) were compared across cohorts. Treatment patterns including receipt of surgery, radiation, chemotherapy, aromatase inhibitors (AI), and non-AI hormonal therapy were evaluated for study cohort patients with at least 2 months of follow-up. Kaplan-Meier survival analysis was also conducted. Results 325 women with stage IV ER + BC without HER2 targeted therapy were identified and matched to 325 women without cancer. Mean age was 77 years for both cohorts, with average follow-up of 18 months for study patients and 26 months for comparison patients. Compared to the comparison cohort, study patients had significantly higher mortality (60.3% versus 31.1%, P < 0.001), shorter survival (survival at 36 months 28% vs. 62%) and higher resource utilization across all settings except for oral prescription drugs. Total PPPM healthcare costs were also significantly higher among study patients ($7,271 vs. $1,778, P < 0.001). Approximately 57% of study patients with 2+ months of follow-up received chemotherapy and over 62% received an AI during follow-up. Within 4 months of cancer diagnosis, surgery and radiation were received by 39% and 32% of study patients, respectively. Conclusions We found significant excess clinical and economic burden among women with stage IV ER + breast cancer who did not receive HER2 targeted therapy. Future studies with more precise and recent data are warranted to confirm and extend these results.
    BMC Health Services Research 07/2014; 14(1):298. DOI:10.1186/1472-6963-14-298 · 1.71 Impact Factor
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    • "We could not directly assess cancer recurrence and had to ‘triangulate’ using medicines and services used to treat recurrence. This method of ascertaining breast cancer recurrence has been successfully demonstrated using administrative health service data in previous studies (Earle et al. 2002; Lamont et al. 2006; Stokes et al. 2008). The validity of recurrence using this method has also been compared with chart review with a reported sensitivity and specificity of 92% and 94% respectively (Earle et al. 2002). "
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    ABSTRACT: Purpose Despite evidence supporting at least five years of endocrine therapy for early breast cancer, many women discontinue therapy early. We investigated the impact of initial therapy type and specific comorbidities on discontinuation of endocrine therapy in clinical practice. Methods We identified women in a population-based cohort with a diagnosis of early breast cancer and an incident dispensing of anastrozole, letrozole or tamoxifen from 2003–2008 (N = 1531). Pharmacy and health service data were used to determine therapy duration, treatment for pre-existing and post-initiation comorbidities (anxiety, depression, hot flashes, musculoskeletal pain, osteoporosis, vaginal atrophy), demographic and other clinical characteristics. Time to discontinuation of initial, and any, endocrine therapy was calculated. Cox regression determined the association of different characteristics on early discontinuation. Results Initial endocrine therapy continued for a median of 2.2 years and any endocrine therapy for 4.8 years. Cumulative probability of discontinuing any therapy was 17% after one year and 58% by five years. Initial tamoxifen, pre-existing musculoskeletal pain and newly-treated anxiety predicted shorter initial therapy but not discontinuation of any therapy. Early discontinuation of any therapy was associated with newly-treated hot flashes (HR = 2.1, 95% CI = 1.3–3.3), not undergoing chemotherapy (HR = 1.4, 95% CI = 1.1–1.8) and not undergoing mastectomy (HR = 1.5, 95% CI = 1.2–1.8). Conclusions Less than half of women completed five years of endocrine therapy. Women at greatest risk of stopping any therapy early were those with newly-treated hot flashes, no initial chemotherapy, or no initial mastectomy. This suboptimal use means that the reductions in recurrence demonstrated in clinical trials may not be realised in practice.
    SpringerPlus 06/2014; 3(1):282. DOI:10.1186/2193-1801-3-282
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    • "For recurrent patients, distant recurrence was identified by an ICD- 9-CM code in the medical claims for secondary cancer (197.XX–198.XX), excluding breast (198.81, 198.82) and lymph node (196.XX) [30] [31]. The number and location of metastases were identified using the specific ICD-9-CM diagnosis codes for recurrence. "
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    ABSTRACT: Background. Trastuzumab improves survival in HER2-positive women with metastatic breast cancer (MBC). The consequences of longer survival include a higher likelihood of additional metastases, including those in the central nervous system (CNS). The effect of CNS metastases on both trastuzumab discontinuation and survival in older patients has not been described. Patients and Methods. We used the Surveillance Epidemiology and End Results (SEER) Medicare data to identify a cohort of 562 women age 66 or older with MBC who were diagnosed between January 1, 2000 and December 31, 2005, free of CNS metastases, and initiated trastuzumab after MBC diagnosis. Time to discontinuation and time to death were analyzed using proportional hazards models. Results. Newly diagnosed CNS metastases were associated with both higher risk of trastuzumab discontinuation (relative hazard [RH] = 1.78, 95% CI 1.11-2.87) and higher risk of death (RH = 2.49, 95% CI 1.84-3.37). The incidence rate of new CNS metastases was comparable among various sites of metastasis (10.7 to 14.7 per 1,000 patient-months), except for bone which was higher (24.1 per 1,000). Conclusion. The diagnosis of CNS metastases was associated with an increase in both the likelihood of discontinuing trastuzumab therapy as well as the risk of death.
    Journal of Cancer Epidemiology 04/2012; 2012:819210. DOI:10.1155/2012/819210
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