Advertisement

Annual cost-savings with the implementation of estrogen-receptor-only testing on Ductal Carcinoma in Situ specimens

Published:October 18, 2022DOI:https://doi.org/10.1016/j.amjsurg.2022.09.060

      Highlights

      • ER status is important in determining DCIS treatment.
      • Cost-savings with omission of routine PR testing for DCIS is $4.3 million.
      • PR testing should only be performed for ER negative DCIS.

      Abstract

      Background

      In DCIS, ER status is an important marker. The utility of concomitant PR testing remains unclear.

      Methods

      A single-institution retrospective cohort study was performed with a comparative analysis of the NCDB to assess annual cost-savings with omission of routine PR testing. National Medicare payment standards determined PR staining costs to be $124.92.

      Results

      150 institutional DCIS cases with receptor data were identified. 104 (69%) were ER+/PR+, 16 (11%) were ER+/PR-, and none were ER-/PR+. Omission of routine PR testing would have resulted in $18,738 saved annually. Within the NCDB, 34,100 DCIS cases had receptor data: 29,277 (85.9%) patients were ER+, and 26,008 (76%) were both ER/PR+. 211 (0.6%) patients were ER-/PR+. Annual national cost-savings with omission of routine PR-testing would have been $4.3 million.

      Conclusion

      PR testing for DCIS should be reserved only for patients with ER- DCIS undergoing breast conservation to determine the utility of adjuvant endocrine therapy.

      Graphical abstract

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Allred D.C.
        • Anderson S.J.
        • Paik S.
        • et al.
        Adjuvant tamoxifen reduces subsequent breast cancer in women with estrogen receptor-positive ductal carcinoma in situ: a study based on NSABP protocol B-24.
        J Clin Oncol. 2012; 30: 1268-1273https://doi.org/10.1200/JCO.2010.34.0141
        • Fu F.
        • Gilmore R.C.
        • Jacobs L.K.
        Ductal carcinoma in situ.
        Surg Clin. 2018; 98: 725-745https://doi.org/10.1016/j.suc.2018.03.007
        • Lari S.A.
        • Kuerer H.M.
        Biological markers in DCIS and risk of breast recurrence: a systematic review.
        J Cancer. 2011; 2 (Published 2011 May 1): 232-261https://doi.org/10.7150/jca.2.232
        • Ryser M.D.
        • Hendrix L.H.
        • Worni M.
        • Liu Y.
        • Hyslop T.
        • Hwang E.S.
        Incidence of ductal carcinoma in situ in the United States, 2000-2014.
        Cancer Epidemiol Biomarkers Prev. 2019; 28: 1316-1323https://doi.org/10.1158/1055-9965.EPI-18-1262
        • Ward E.M.
        • DeSantis C.E.
        • Lin C.C.
        • et al.
        Cancer statistics: breast cancer in situ.
        CA A Cancer J Clin. 2015; 65: 481-495https://doi.org/10.3322/caac.21321
        • Solin L.J.
        Management of ductal carcinoma in situ (DCIS) of the breast: present approaches and future directions.
        Curr Oncol Rep. 2019; 21 (Published 2019 Mar 5): 33https://doi.org/10.1007/s11912-019-0777-3
        • Hefti M.M.
        • Hu R.
        • Knoblauch N.W.
        • et al.
        Estrogen receptor negative/progesterone receptor positive breast cancer is not a reproducible subtype.
        Breast Cancer Res. 2013; 15: R68https://doi.org/10.1186/bcr3462
        • Olivotto I.A.
        • Truong P.T.
        • Speers C.H.
        • et al.
        Time to stop progesterone receptor testing in breast cancer management.
        J Clin Oncol. 2004; 22: 1769-1770https://doi.org/10.1200/JCO.2004.99.251
        • Colozza M.
        • Larsimont D.
        • Piccart M.J.
        Progesterone receptor testing: not the right time to be buried.
        J Clin Oncol. 2005; 23: 3867-3870https://doi.org/10.1200/JCO.2005.05.167
        • Allison K.H.
        • Hammond M.E.H.
        • Dowsett M.
        • et al.
        Estrogen and progesterone receptor testing in breast cancer: ASCO/CAP guideline update.
        J Clin Oncol. 2020; 38: 1346-1366https://doi.org/10.1200/JCO.19.02309
        • Hammond M.E.
        • Hayes D.F.
        • Dowsett M.
        • et al.
        American Society of Clinical Oncology/College of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer [published correction appears in J Clin Oncol. 2010 Jul 20;28(21):3543].
        J Clin Oncol. 2010; 28: 2784-2795https://doi.org/10.1200/JCO.2009.25.6529
        • Hughes K.S.
        • Schnaper L.A.
        • Berry D.
        • et al.
        Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer.
        N Engl J Med. 2004; 351: 971-977https://doi.org/10.1056/NEJMoa040587
        • Calderon E.
        • Webb C.
        • Kosiorek H.E.
        • et al.
        Are we choosing wisely in elderly females with breast cancer?.
        Am J Surg. 2019; 218: 1229-1233https://doi.org/10.1016/j.amjsurg.2019.08.004
        • Fisher B.
        • Dignam J.
        • Wolmark N.
        • et al.
        Tamoxifen in treatment of intraductal breast cancer: national Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial.
        Lancet. 1999; 353: 1993-2000https://doi.org/10.1016/S0140-6736(99)05036-9
        • Fisher B.
        • Bauer M.
        • Margolese R.
        • et al.
        Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer.
        N Engl J Med. 1985; 312: 665-673https://doi.org/10.1056/NEJM198503143121101
        • Giuliano A.E.
        • Ballman K.V.
        • McCall L.
        • et al.
        Effect of axillary dissection vs No axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: the ACOSOG Z0011 (alliance) randomized clinical trial.
        JAMA. 2017; 318: 918-926https://doi.org/10.1001/jama.2017.11470
        • Byun D.J.
        • Wu S.P.
        • Nagar H.
        • Gerber N.K.
        Ductal carcinoma in situ in young women: increasing rates of mastectomy and variability in endocrine therapy use.
        Ann Surg Oncol. 2021; 28: 6083-6096https://doi.org/10.1245/s10434-021-09972-2
        • VandenBussche C.J.
        • Cimino-Mathews A.
        • Park B.H.
        • Emens L.A.
        • Tsangaris T.N.
        • Argani P.
        Reflex estrogen receptor (ER) and progesterone receptor (PR) analysis of ductal carcinoma in situ (DCIS) in breast needle core biopsy specimens: an unnecessary exercise that costs the United States $35 million/y.
        Am J Surg Pathol. 2016; 40: 1090-1099https://doi.org/10.1097/PAS.0000000000000674
        • Narod S.A.
        • Iqbal J.
        • Giannakeas V.
        • Sopik V.
        • Sun P.
        Breast cancer mortality after a diagnosis of ductal carcinoma in situ.
        JAMA Oncol. 2015; 1: 888-896https://doi.org/10.1001/jamaoncol.2015.2510
        • Cuzick J.
        • Sestak I.
        • Pinder S.E.
        • et al.
        Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial.
        Lancet Oncol. 2011; 12: 21-29https://doi.org/10.1016/S1470-2045(10)70266-7
        • Barrio A.V.
        • Van Zee K.J.
        Controversies in the treatment of ductal carcinoma in situ.
        Annu Rev Med. 2017; 68: 197-211https://doi.org/10.1146/annurev-med-050715-104920
        • Karavites L.C.
        • Kane A.K.
        • Zaveri S.
        • et al.
        Tamoxifen acceptance and adherence among patients with ductal carcinoma in situ (DCIS) treated in a multidisciplinary setting.
        Cancer Prev Res (Phila). 2017; 10: 389-397https://doi.org/10.1158/1940-6207.CAPR-17-0029
        • Wink C.J.
        • Woensdregt K.
        • Nieuwenhuijzen G.A.
        • et al.
        Hormone treatment without surgery for patients aged 75 years or older with operable breast cancer.
        Ann Surg Oncol. 2012; 19: 1185-1191https://doi.org/10.1245/s10434-011-2070-z
        • Frebault J.
        • Bergom C.
        • Cortina C.S.
        • et al.
        Invasive breast cancer treatment patterns in women age 80 and over: a report from the national cancer database.
        Clin Breast Cancer. 2022; 22: 49-59https://doi.org/10.1016/j.clbc.2021.07.00
        • Cortina C.S.
        • Agarwal S.
        • Mulder L.L.
        • et al.
        Are providers and patients following hormonal therapy guidelines for patients over the age of 70? The influence of CALGB 9343.
        Clin Breast Cancer. 2018; 18: e1289-e1292https://doi.org/10.1016/j.clbc.2018.07.004
        • Blumen H.
        • Fitch K.
        • Polkus V.
        Comparison of treatment costs for breast cancer, by tumor stage and type of service.
        Am Health Drug Benefits. 2016; 9: 23-32
        • Offodile 2nd, A.C.
        • Asaad M.
        • Boukovalas S.
        • et al.
        Financial toxicity following surgical treatment for breast cancer: a cross-sectional pilot study.
        Ann Surg Oncol. 2021; 28: 2451-2462https://doi.org/10.1245/s10434-020-09216-9
        • Resnicow K.
        • Patel M.R.
        • Mcleod M.C.
        • Katz S.J.
        • Jagsi R.
        Physician attitudes about cost consciousness for breast cancer treatment: differences by cancer sub-specialty.
        Breast Cancer Res Treat. 2019. Jan; 173 (Epub 2018 Sep 26. PMID: 30259283; PMCID: PMC8968296): 31-36https://doi.org/10.1007/s10549-018-4976-7
        • Badve S.S.
        • Gökmen-Polar Y.
        Ductal carcinoma in situ of breast: update 2019.
        Pathology. 2019; 51: 563-569https://doi.org/10.1016/j.pathol.2019.07.005
        • Kline R.M.
        Bundled payment Models in Oncology: learning to think in new ways.
        JCO Oncol Pract. 2021; 17: 169-172https://doi.org/10.1200/OP.20.00735
      1. Centers for Medicare and medicaid services.