Chemoprevention: drug pricing and mortality: the case of tamoxifen.

BACKGROUND: Tamoxifen is a prototypic cancer chemopreventive agent, yet clinical trials have not evaluated its effect on mortality or the impact of drug pricing on its cost-effectiveness. METHODS: A state-transition Markov model for a hypothetical cohort of women age 50 years was used to evaluate the effects of tamoxifen on mortality and tamoxifen price on cost-effectiveness. Incidence and mortality rates for breast and endometrial cancers were derived from Surveillance, Epidemiology and End Results statistics, and noncancer outcomes were obtained from published studies. Relative risks of outcomes were derived from the National Surgical Adjuvant Breast and Bowel Project P-1 trial. Costs were based on Medicare reimbursements. RESULTS: Projected overall mortality for women at 1.67% 5-year breast cancer risk showed little difference with or without tamoxifen, resulting in a cost-effectiveness ratio of $1,335,690 per life-year saved as a result of tamoxifen use. Adjusting for the differential impact of estrogen receptor-negative cancers, tamoxifen increased mortality for women with a uterus until the 5-year breast cancer risk reached > or =2.1%. Assigning the Canadian price for tamoxifen dramatically reduced the incremental cost (to $123,780 per life-year saved). At that price, the use of tamoxifen was less costly and more effective for women with 5-year breast cancer risks >4%. CONCLUSIONS: Tamoxifen may increase mortality in women at the lower end of the "high-risk" range for breast cancer. If prices in the U.S. approximated Canadian prices, then tamoxifen use for breast cancer risk reduction in women with a 5-year risk >3% could be a reasonable strategy to reduce the incidence of breast cancer. Because they are used by many unaffected individuals, the price of chemopreventive agents has a major influence on their cost-effectiveness.

Preferences of Women Evaluating Risks of Tamoxifen (POWER) study of preferences for tamoxifen for breast cancer risk reduction.

BACKGROUND: The objective of this study was to understand the attitudes and preferences of risk-eligible women regarding use of tamoxifen for breast cancer risk reduction. METHODS: A cross-sectional, mixed-methods interview study was conducted at a university medical center and at community sites. Participants were women who had an estimated 5-year breast cancer risk > or = 1.7% and no prior breast cancer. Interviews were conducted in English or Spanish. The interview included a 15-minute, standardized educational session on the potential benefits and harms of tamoxifen followed by close-ended and open-ended questions about participants' inclinations to take tamoxifen and factors important to their decision. A demographic questionnaire, a test on knowledge of potential benefits and harms of tamoxifen, and an interview evaluation were included. RESULTS: Two hundred fifty-five women completed interviews. Their estimated mean 5-year breast cancer risk was 2.8%; and their mean self-perceived 5-year risk was 32.7%. After the educational intervention, 45 women (17.6%) were inclined to take tamoxifen. Very high risk women (> 3.5%) were no more inclined to take it than women with lower risk (1.7-3.5%). In a multivariable analysis, lower income, confidence in the effectiveness of tamoxifen, and concern about fractures were associated with being inclined to take it; concern about pulmonary embolism, dyspareunia, cataracts, and low self-perceived breast cancer risk were associated negatively with taking tamoxifen. Participants expressed concerns about adverse effects. CONCLUSIONS: Less than 20% of women were interested in tamoxifen after education about potential benefits and harms, despite a very high self-perceived breast cancer risk. Candidate chemoprevention agents must have few potential adverse effects to achieve widespread acceptance.

Walk a mile in my shoes: a chronic illness care workshop for first-year students.

BACKGROUND AND OBJECTIVES: A number of educators and recent medical school graduates have suggested a need to expand predoctoral training in chronic illness care. We developed a workshop to enhance first-year students' self-awareness regarding attitudes toward chronic illness care and to help them communicate effectively around patient self-care. METHODS: Students participated in a two-part workshop incorporating lectures, patient-centered interviewing role-plays, and an assignment requiring students to "have" a chronic illness and perform self-care tasks for 2 weeks. We assessed impact on chronic care knowledge by comparing pre- and post-workshop quiz scores. We also reviewed student evaluations of the experience. RESULTS: Of 96 students, 86 (90%) attended Session 1, and 91 (95%) attended Session 2. The mean (standard deviation) knowledge score improved from 6.4 (1.5) before the workshop to 8.4 (1.2) after the workshop (10 points possible). Of 53 students (55%) who completed an evaluation, most perceived the value of the workshop, including the self-care assignment and role-plays. Some felt more positively about chronic illness care following the workshop, and many indicated additional chronic care training in the clinical years would be welcome. CONCLUSIONS: An introductory workshop for first-year students led to increased knowledge of and improved attitudes toward chronic illness care. Longitudinal training in chronic illness care should be considered in predoctoral education.