Economic evaluation of using a genetic test to direct breast cancer chemoprevention in white women with a previous breast biopsy.

BACKGROUND: Tamoxifen therapy reduces the risk of breast cancer but increases the risk of serious adverse events including endometrial cancer and thromboembolic events. OBJECTIVES: The cost effectiveness of using a commercially available breast cancer risk assessment test (BREVAGen™) to inform the decision of which women should undergo chemoprevention by tamoxifen was modeled in a simulated population of women who had undergone biopsies but had no diagnosis of cancer. METHODS: A continuous time, discrete event, mathematical model was used to simulate a population of white women aged 40-69 years, who were at elevated risk for breast cancer because of a history of benign breast biopsy. Women were assessed for clinical risk of breast cancer using the Gail model and for genetic risk using a panel of seven common single nucleotide polymorphisms. We evaluated the cost effectiveness of using genetic risk together with clinical risk, instead of clinical risk alone, to determine eligibility for 5 years of tamoxifen therapy. In addition to breast cancer, the simulation included health states of endometrial cancer, pulmonary embolism, deep-vein thrombosis, stroke, and cataract. Estimates of costs in 2012 US dollars were based on Medicare reimbursement rates reported in the literature and utilities for modeled health states were calculated as an average of utilities reported in the literature. A 50-year time horizon was used to observe lifetime effects including survival benefits. RESULTS: For those women at intermediate risk of developing breast cancer (1.2-1.66 % 5-year risk), the incremental cost-effectiveness ratio for the combined genetic and clinical risk assessment strategy over the clinical risk assessment-only strategy was US$47,000, US$44,000, and US$65,000 per quality-adjusted life-year gained, for women aged 40-49, 50-59, and 60-69 years, respectively (assuming a price of US$945 for genetic testing). Results were sensitive to assumptions about patient adherence, utility of life while taking tamoxifen, and cost of genetic testing. CONCLUSIONS: From the US payer's perspective, the combined genetic and clinical risk assessment strategy may be a moderately cost-effective alternative to using clinical risk alone to guide chemoprevention recommendations for women at intermediate risk of developing breast cancer.

Cost-effectiveness of a genetic test for breast cancer risk.

Genetic testing of seven single-nucleotide polymorphisms (7SNP) can improve estimates of risk of breast cancer relative to the Gail risk test alone, for the purpose of recommending MRI screening for women at high risk. A simulation of breast cancer and health care processes was used to conduct a virtual trial comparing the use of the 7SNP test with the Gail risk test to categorize patients by risk. Average-risk patients received annual mammogram, whereas high-risk patients received annual MRI. Cancer incidence was based on Surveillance, Epidemiology, and End Results data and validated to Cancer Prevention Study II Nutrition Cohort data. Risk factor values were drawn from National Health and Nutrition Examination Survey (NHANES-4) and Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial data. Mammogram characteristics were derived from Breast Cancer Surveillance Consortium data. The test was most cost-effective when given to patients at an intermediate lifetime risk of breast cancer. For patients with a risk of 16% to 28%, it resulted in a 1.91% reduction in cancer deaths, saving 0.005 quality-adjusted life years per person at a cost of $163,264 per QALY. These results were sensitive to the age at which the test is given, the discount rate, and the costs of the genetic test and MRI. The cost effectiveness of using the 7SNP test for patients with intermediate Gail risk is similar to that of other recommended strategies, including annual MRI for patients with a lifetime risk greater than 20% or BRCA1/2 mutations.

Daphnia predation on the amphibian chytrid fungus and its impacts on disease risk in tadpoles.

Direct predation upon parasites has the potential to reduce infection in host populations. For example, the fungal parasite of amphibians, Batrachochytrium dendrobatidis (Bd), is commonly transmitted through a free-swimming zoospore stage that may be vulnerable to predation. Potential predators of Bd include freshwater zooplankton that graze on organisms in the water column. We tested the ability of two species of freshwater crustacean (Daphnia magna and D. dentifera) to consume Bd and to reduce Bd density in water and infection in tadpoles. In a series of laboratory experiments, we allowed Daphnia to graze in water containing Bd while manipulating Daphnia densities, Daphnia species identity, grazing periods and concentrations of suspended algae (Ankistrodesmus falcatus). We then exposed tadpoles to the grazed water. We found that high densities of D. magna reduced the amount of Bd detected in water, leading to a reduction in the proportion of tadpoles that became infected. Daphnia dentifera, a smaller species of Daphnia, also reduced Bd in water samples, but did not have an effect on tadpole infection. We also found that algae affected Bd in complex ways. When Daphnia were absent, less Bd was detected in water and tadpole samples when concentrations of algae were higher, indicating a direct negative effect of algae on Bd. When Daphnia were present, however, the amount of Bd detected in water samples showed the opposite trend, with less Bd when densities of algae were lower. Our results indicate that Daphnia can reduce Bd levels in water and infection in tadpoles, but these effects vary with species, algal concentration, and Daphnia density. Therefore, the ability of predators to consume parasites and reduce infection is likely to vary depending on ecological context.

An estrogen model: the relationship between body mass index, menopausal status, estrogen replacement therapy, and breast cancer risk.

We present a mathematical model that lends support to the hypothesis that estrogen levels mediate the complex relationship between body mass index (BMI), menopausal status, estrogen-only hormone replacement therapy (HRT), and breast cancer risk. The model predicts a decrease in the relative risk of breast cancer of 3% per unit increase in BMI (kg/m(2)) for premenopausal women and an increase in the relative risk of 4% per unit increase in BMI for postmenopausal women who are not HRT users. When comparing postmenopausal women who use estrogen-only HRT to postmenopausal women who do not use HRT, the model predicts an increased risk of breast cancer associated with use of estrogen that diminishes with increasing BMI, with a relative risk of 1.6 for women with BMI of 18, 1.2 for women with BMI of 25, and 1.0 for women with BMI ≥ 30. Model predictions agree with data from five major epidemiological studies.

Cost-effectiveness of chemoprevention of breast cancer using tamoxifen in a postmenopausal US population.

BACKGROUND: Previous cost-effectiveness analyses of tamoxifen therapy account for breast cancer risk reduction during active treatment but not for its persistent protective effect after active treatment. METHODS: A detailed, continuous time, mathematical model of breast cancer and healthcare processes was used to simulate a postmenopausal population aged <55 years in a virtual trial comparing tamoxifen treatment with no treatment for lifetime follow-up. Unlike previous work, the current model of tamoxifen therapy is based on a meta-analysis of 4 randomized, placebo-controlled chemoprevention trials with breast cancer risk reduction continuing for 10 years after treatment termination. Cancer incidence and survival data were derived from Surveillance, Epidemiology and End Results statistics. Noncancer disease incidences, quality-adjusted life year (QALY) utility weights, and costs were derived from the literature. RESULTS: Tamoxifen treatment (vs no treatment) saved 29 QALYs in a population of 1000 postmenopausal women aged <55 years with an additional cost of $333,000 over the population's lifetime (average cost-effectiveness ratio, $11,530 per QALY). Tamoxifen therapy, compared with no treatment, was cost saving when higher risk populations were targeted (5-year risk ≥1.66%). The cost-effectiveness results were sensitive to parameters that characterized menopausal symptoms and adverse side effects of tamoxifen. CONCLUSIONS: The current results indicated that tamoxifen chemoprophylaxis for postmenopausal women aged <55 years is a cost-effective health policy that reduces breast cancer incidence and improves life expectancy. Focusing on a postmenopausal population aged <55 years minimized the threat of adverse events associated with tamoxifen.

Acute toxicity of acidity in larvae and adults of four stream salamander species (Plethodontidae).

High levels of acid deposition have severely affected streamwater chemistry in the southern Appalachians. Plethodontid stream salamanders living in and around headwater streams rely on cutaneous respiration and are highly susceptible to changes in water quality. We examined the sensitivity to low pH conditions in four stream salamanders by monitoring the response to six pH treatments ranging from pH 2.75 to 6.5. To quantify acid tolerance, we determined median lethal concentrations (LC50) in 96-h laboratory bioassays. This is the first study to quantify the level of sensitivity of stream salamanders to acidic conditions, indicating that stream salamanders are acid tolerant compared with many other lotic organisms. We found that acid tolerance is a species-specific trait with intraspecific variation shaped by life stage and body size. Mortality occurred at pH levels less than 4.2. The acid sensitivity of Desmognathus quadramaculatus larvae (LC50 = pH 3.95) was highest compared to sensitivity of Eurycea cirrigera larvae (LC50 = 3.6), Gyrinophilus porphyriticus larvae (LC50 = 3.5), and Pseudotriton ruber larvae (LC50 = 3.5). Larval survival was lower than adult survival in low pH treatments for E. cirrigera (adult LC50 = 3.1) and D. quadramaculatus (adult LC50 = 3.5). Salamanders responded to sublethal exposure to acidity with lethargic movements and decreased swimming speed. These results suggest that episodic acid events that cause streamwater pH to drop near 4.2 may cause mortality or induce sublethal effects, such as slower swimming speed. Because salamander larvae are more sensitive to acidic conditions than adults, we recommend that population monitoring programs extend methodology to include reliable estimates of larval population sizes.

Nucleotide variation, haplotype structure, and association with end-stage renal disease of the human interleukin-1 gene cluster.

A dense gene-based SNP map was constructed across a 360-kb region containing the interleukin-1 gene cluster (IL1A, IL1B, and IL1RN), focusing on IL1RN. In total, 95 polymorphisms were confirmed or identified primarily by direct sequencing. Polymorphisms were precisely mapped to completed BAC and genomic sequences spanning this region. The polymorphisms were typed in 443 case-control subjects from Caucasian and African American groups. Consecutive pair-wise marker linkage disequilibrium was not strictly correlated with distance and ranged from D'=0.0079 to 1.000 and D'=0.0521 to 1.0000 in Caucasians and African Americans, respectively. Single markers and haplotypes in IL1 cluster genes were evaluated for association with end-stage renal disease (ESRD). Eleven SNPs show some evidence of association with ESRD, with the strongest associations in two IL1A variants, one SNP, rs1516792-3, in intron 5 (p=0.0015) and a 4-bp insertion/deletion within the 3'UTR, rs16347-2 (p=0.0024), among African Americans with non-T2DM-associated ESRD.

Visualizing human leukocyte antigen class II risk haplotypes in human systemic lupus erythematosus.

Human leukocyte antigen (HLA) class I and class II alleles are implicated as genetic risk factors for many autoimmune diseases. However, the role of the HLA loci in human systemic lupus erythematosus (SLE) remains unclear. Using a dense map of polymorphic microsatellites across the HLA region in a large collection of families with SLE, we identified three distinct haplotypes that encompassed the class II region and exhibited transmission distortion. DRB1 and DQB1 typing of founders showed that the three haplotypes contained DRB1*1501/ DQB1*0602, DRB1*0801/ DQB1*0402, and DRB1*0301/DQB1*0201 alleles, respectively. By visualizing ancestral recombinants, we narrowed the disease-associated haplotypes containing DRB1*1501 and DRB1*0801 to an approximately 500-kb region. We conclude that HLA class II haplotypes containing DRB1 and DQB1 alleles are strong risk factors for human SLE.