Abstract P6-11-03: A cost effectiveness analysis of baseline left ventricular function assessment for breast cancer patients undergoing anthracycline chemotherapy
Authors: Safonov A , Hatzis C , Stratton J , Gross CP , Russell R , Pusztai L , Abu-Khalaf MM 
Published: May 2016

Abstract
Background: It is unclear if all breast cancer (BC) patients require baseline left ventricular function (LVEF) assessment prior to anthracycline based chemotherapy (ABC), and the approach is variable in clinical practice. Our objective is to determine the cost effectiveness of obtaining a baseline LVEF assessment prior to (neo) adjuvant ABC in clinical practice.
Methods: We performed a retrospective analysis of the Yale Equilibrium Radionuclide Angiography (ERNA) database for 701 breast cancer patients who had a baseline ERNA scan prior to systemic therapy for an initial diagnosis of stages I-IV BC between July 2003 and May 2013. We found that 14 of 701 (2%) patients had a baseline LVEF &lt; 50%. Age, pre-existing cardiac risk factors and coronary artery disease did not predict an abnormal baseline LVEF &lt;50 %. To evaluate the benefit of obtaining a baseline echocardiogram or ERNA before ABC, we considered the screening scenario in which BC patients with a baseline LVEF &lt; 50% on screening echocardiogram are treated with a second (2nd) generation non-ABC and those with baseline LVEF ≥ 50% receive a third (3rd) generation ABC, and compared this with a non-screening scenario with uniform 3rd generation ABC treatment for all patients who do not have a baseline echocardiogram. We used Adjuvant Online to obtain estimates of the disease free (DFS) and overall survival (OS) for a 3rd generation ABC regimen vs a 2nd generation non-ABC regimen for 50 year old patients with a T2N1 hormone receptor positive BC. We implemented these oncologic clinical outcomes (in addition to cardiotoxicity-related clinical outcomes, costs of screening echocardiogram and treatment of congestive heart failure (CHF), quality of life metrics, as reported in the literature) into a simplified decision-analytic cost-effectiveness analysis that accounts for the different disease states and their associated costs and quality of life outcomes.
Results: Assuming that 20% of the unscreened patients with a LVEF &lt; 50% will develop CHF if treated with ABC regimen without management of baseline cardiac dysfunction, the base case incremental cost effectiveness ratio (ICER) was determined to be 18,520 $USD/QALY. Sensitivity analysis suggested that the cost-effectiveness of baseline LVEF assessment is primarily driven by the prevalence of patients with LVEF &lt; 50%, the incidence of CHF in this high-risk patient group if treated with ABC regimen, and time to CHF development. While our analysis did not reveal risk factors predictive of low baseline LVEF, our model's dependence on prevalence of LVEF &lt; 50% demonstrates the importance of risk factor stratification. A hypothetical predictive marker which enriches the prevalence of an abnormal baseline LVEF 5-fold to 10% would result in a cost-effectiveness of 10,990 $USD/QALY. The model is less sensitive to the cost of baseline echocardiogram testing.
Conclusion: Baseline LVEF assessment was found to be cost-effective under a willingness-to-pay threshold of $50,000/QALY. Our sensitivity analysis suggests that risk factor-guided LVEF baseline LVEF screening may increase the number of high-risk patients in the treatment population, thus further increasing the cost-effectiveness of baseline LVEF assessment.
Citation Format: Safonov A, Hatzis C, Stratton J, Gross CP, Russell R, Pusztai L, Abu-Khalaf MM. A cost effectiveness analysis of baseline left ventricular function assessment for breast cancer patients undergoing anthracycline chemotherapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-11-03.