Disease Management and Health Outcomes

, Volume 8, Issue 4, pp 197–210 | Cite as

Breast Cancer Epidemiology, Prevention and Costs of Care

Implications for Disease Management Programmes
Review Article


Breast cancer is the most frequently diagnosed cancer in women and the second leading cause of cancer mortality. It is estimated to account for approximately 20% of all cancer expenditures, making the burden of disease relatively high. One of the most important risk factors for developing breast cancer is age; with demographic trends towards an increasing elderly population in the US, this burden is likely to increase. Recent trends in healthcare delivery have increased the emphasis on evaluating costs of providing care as well as the outcomes of that care.

This paper reviews breast cancer epidemiology, primary and secondary prevention and costs of breast cancer care by stage of disease at diagnosis and type of service, and discusses implications for the development of disease management programmes. Implementation of disease management programmes, through the creation of a data infrastructure system, establishment of measurable breast health and cancer care outcomes, and programme evaluation may be an important mechanism for managed-care organisations to provide quality and cost-effective breast cancer management.


Breast Cancer Mammography Screening Disease Management Programme Breast Cancer Care Primary Prevention Strategy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Ries LAG, Kosary CL, Hankey BF, et al, editors. SEER cancer statistics review, 1973–1993: tables and graphs. Bethesda (MD): National Cancer Institute, 1998. Report no. NIH 96–2789Google Scholar
  2. 2.
    American Cancer Society. Mammography guidelines [online]. Available from:, [Accessed 1999 Dec 22]
  3. 3.
    Strewing JP, Hartge P, Wacholder S, et al. The risk of cancer associated with specific mutations of BRCA1 and BRCA2 among Ashkenazi Jews. N Engl J Med 1997; 336: 1401–8CrossRefGoogle Scholar
  4. 4.
    Kelsey JL, Gammon MD. Epidemiology of breast cancer. Epidemiol Rev 1990; 12: 228–40PubMedGoogle Scholar
  5. 5.
    Carter CL, Corle DK, Micozzi MS, et al. A prospective study of the development of breast cancer in 16,692 women with benign breast disease. Am J Epidemiol 1988; 128: 467–77PubMedGoogle Scholar
  6. 6.
    Krieger N, Hiatt RA. Risk of breast cancer after benign breast disease: Variation by histologic type, degree of atypia, age at biopsy, and length of followup. Am J Epidemiol 1992; 135: 619–31PubMedGoogle Scholar
  7. 7.
    Hunter DJ, Willett WC. Diet, body size, and breast cancer. Epidemiol Rev 1993; 15: 110–32PubMedGoogle Scholar
  8. 8.
    Breen N, Kessler L. Changes in the use of screening mammography: evidence from the 1987 and 1990 National Health Interview Surveys. Am J Public Health 1994; 84(1): 62–7PubMedCrossRefGoogle Scholar
  9. 9.
    Longnecker MR. Alcoholic beverage consumption in relation to risk of breast cancer: meta-analysis and review. Cancer Causes Control 1994; 5: 73–82PubMedCrossRefGoogle Scholar
  10. 10.
    Kelsey JL, Bernstein L. Epidemiology and prevention of breast cancer. Ann Rev Public Health 1996; 17: 47–67CrossRefGoogle Scholar
  11. 11.
    Helzlsouer K. Early detection and prevention of breast cancer. In: Greenwald P, Kramer BS, Weed DL, editors. Cancer prevention and control. New York: Marcel Dekker, 1995Google Scholar
  12. 12.
    Schuette HL, Tucker TC, Brown ML, et al. The costs of cancer care in the United States: implications for action. Oncology 1995; 9 (11 Suppl. 1): 19–22PubMedGoogle Scholar
  13. 13.
    Blackman DK, Bennett EM, Miller DS. Trends in self-reported use of mammograms (1989–1997) and Papanicolaou tests (1991–1997) — behavioral risk factor surveillance system. MMWR Morb Mortal Wkly Rep 1999; 48: 1–23Google Scholar
  14. 14.
    Bodenheimer T. Disease management — promises and pitfalls. N Engl J Med 1999; 340: 1202–5PubMedCrossRefGoogle Scholar
  15. 15.
    Armstrong EP. Disease management: state of the art and future directions. Clin Ther 1999; 21: 593–609PubMedCrossRefGoogle Scholar
  16. 16.
    Coons SJ. Disease management. Definitions and explorations of issues. Clin Ther 1996; 18: 1321–6PubMedCrossRefGoogle Scholar
  17. 17.
    Bierman AS, Clancy CM. Women’s health. Chronic disease, and disease management: new words and old music? Womens’s Health Issues 1999; 9: 2–17CrossRefGoogle Scholar
  18. 18.
    Schulman KA, Mark DB, Califf RM. Outcomes and costs within a disease management programme for congestive heart failure. Am Heart J 1998; 135: S285–S292PubMedCrossRefGoogle Scholar
  19. 19.
    Gervitz F, Corrato RR, Chodorr P, et al. Chronic disease, women’s health, and ‘disease management’: the latest trend? Womens’s Health Issues 1999; 9: 18–29CrossRefGoogle Scholar
  20. 20.
    Early Breast Cancer Trialists’ Collaborative Group. Systemic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy. Lancet 1992; 339: 1–15Google Scholar
  21. 21.
    Early Breast Cancer Trialists’ Collaborative Group. Systemic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy. Lancet 1992; 339: 71–85Google Scholar
  22. 22.
    Eley JW, Hill HA, Chen VW, et al. Racial differences in survival from breast cancer. Results of the National Cancer Institute Black/White Cancer Survival Study. JAMA 1994; 272(12): 947–54PubMedCrossRefGoogle Scholar
  23. 23.
    Fletcher SW, Black W, Harris R, et al. Report of the International Workshop on Screening for Breast Cancer. J Natl Cancer Inst 1993; 85(20): 1644–56PubMedCrossRefGoogle Scholar
  24. 24.
    Kerlikowske K, Grady D, Rubin SM, et al. Efficacy of screening mammography: a meta-analysis. JAMA 1995; 273: 149–54PubMedCrossRefGoogle Scholar
  25. 25.
    Andersson I, Aspegren K, Janzon L, et al. Mammographic screening and mortality from breast cancer: the Malmo mammographie screening trial. BMJ 1988; 297(6654): 943–8PubMedCrossRefGoogle Scholar
  26. 26.
    Roberts MM, Alexander FE, Anderson TJ, et al. Edinburgh trial of screening for breast cancer: mortality at seven years. Lancet 1990; 335(8684): 241–6PubMedCrossRefGoogle Scholar
  27. 27.
    Shapiro S. Periodic screening for breast cancer: The HIP randomized controlled trial. J Natl Cancer Inst Monogr 1997; 22: 27–30PubMedGoogle Scholar
  28. 28.
    Nystrom L, Rutqvist LE, Wall S, et al. Breast cancer screening with mammography: overview of Swedish randomised trials. Lancet 1993; 341(8851): 973–8PubMedCrossRefGoogle Scholar
  29. 29.
    U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. Baltimore (MD): Williams and Wilkins, 1996Google Scholar
  30. 30.
    Saltzman P, Kerlikowske K, Phillips K. Cost-effectiveness of extending screening mammography guidelines to include women 40 to 49 years of age. Ann Intern Med 1997; 127: 955–65Google Scholar
  31. 31.
    Kerlikowske K, Salzmann P, Phillips KA, et al. Continuing screening mammography in women aged 70 to 79 years: impact on life expectancy and cost-effectiveness. JAMA 1999 Dec 8; 282(22): 2156–63PubMedCrossRefGoogle Scholar
  32. 32.
    Burns RB, McCarthy EP, Freund KM, et al. Black women receive less mammography even with similar use of primary care. Ann Intern Med 1996; 125: 173–82PubMedGoogle Scholar
  33. 33.
    Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 1999; 340: 77–84PubMedCrossRefGoogle Scholar
  34. 34.
    Schrag D, Kuntz KM, Garber JE, et al. Decision analysis effects of prophylactic mastectomy and oophrectomy on life expectancy among women with BRCA1 or BRCA2 mutations. N Engl J Med 1997; 336: 1465–71PubMedCrossRefGoogle Scholar
  35. 35.
    Grann VR, Panageas KS, Whang W, et al. Decision analysis of prophylatic mastectomy and oophorectomy in BRCA-1 positive or BRCA2-positive patients. J Clin Oncol 1998; 16: 979–85PubMedGoogle Scholar
  36. 36.
    Fisher B, Costantino JP, Wickerham DL, et al. Tamoxifen for prevention of breast cancer. Report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst 1998; 16: 1371–88CrossRefGoogle Scholar
  37. 37.
    Cummings SR, Eckert S, Krueger KA, et al. The effect of raloxifene on risk of breast cancer in postmenopausal women — results from the MORE randomized trial. Multiple Outcomes of Raloxifene Evaluation. JAMA 1999; 281(23): 2189–97PubMedCrossRefGoogle Scholar
  38. 38.
    Henderson MM, Kushi LH, Thompson DJ, et al. Feasibility of a randomized trial of a low-fat diet for the prevention of breast cancer: dietary compliance in the Women’s Health Trial Vanguard Study. Prev Med 1990; 19(2): 115–33PubMedCrossRefGoogle Scholar
  39. 39.
    Lindfors KK, Rosenquist CJ. The cost-effectiveness of mammographic screening strategies. JAMA 1995; 274: 881–4PubMedCrossRefGoogle Scholar
  40. 40.
    Schapira DV, Studnicki J, Bradham DD, et al. Intensive care, survival, and expense of treating critically ill cancer patients. JAMA 1993; 69: 783–6CrossRefGoogle Scholar
  41. 41.
    Mandelblatt JS, Wheat ME, Monane M, et al. Breast cancer screening for elderly women with and without comorbid conditions: a decision analysis model. Ann Intern Med 1992; 116: 722–30PubMedGoogle Scholar
  42. 42.
    Grann VR, Whang W, Jacobson J, et al. Benefits and costs of screening Ashkenazi Jewish women for BRCA1 and BRCA2. J Clin Oncol 1999; 17: 494–500PubMedGoogle Scholar
  43. 43.
    Gold MR, Siegel JE, Russell LB, et al. Cost-effectiveness in health and medicine. 1st ed. New York: Oxford University Press, 1996Google Scholar
  44. 44.
    Hillner BE, Smith TJ. Efficacy and cost effectiveness of adjuvant chemotherapy in women with node-negative breast cancer. N Engl J Med 1991; 324: 160–8PubMedCrossRefGoogle Scholar
  45. 45.
    Desch CE, Hillner BE, Smith TJ, et al. Should the elderly receive chemotherapy for node-negative breast cancer? A cost-effectiveness analysis examining total and active life-expectancy outcomes. J Clin Oncol 1993; 11(4): 777–82PubMedGoogle Scholar
  46. 46.
    Hillner BE, Smith TJ. A model of chemotherapy in node-negative breast cancer. Monogr Natl Cancer Inst 1992; 11: 143–9PubMedGoogle Scholar
  47. 47.
    Hillner BE, Smith TJ, Desch CE. Assessing the cost effectiveness of adjuvant therapies in early breast cancer using a decision analysis model. Breast Cancer Res Treat 1993; 25: 97–105PubMedCrossRefGoogle Scholar
  48. 48.
    Smith TJ, Hillner BE. The efficacy and cost-effectiveness of adjuvant therapy of early breast cancer in premenopausal women. J Clin Oncol 1993; 11: 771–6PubMedGoogle Scholar
  49. 49.
    Hillner BE, Smith TJ, Desch CE. Efficacy and cost-effectiveness of autologous bone marrow transplantation in metastatic breast cancer. Estimates using decision analysis while awaiting clinical trial results. JAMA 1992; 267: 2055–61PubMedCrossRefGoogle Scholar
  50. 50.
    Hillner BE, Smith TJ. Should women with node-negative breast cancer receive adjuvant chemotherapy? Insights from a decision analysis model. Breast Cancer Res Treat 1992; 23: 17–27PubMedCrossRefGoogle Scholar
  51. 51.
    Smith TJ, Hillner BE, Desch CE. Efficacy and cost-effectiveness of cancer treatment: rational allocation of resources based on decision analysis. J Natl Cancer Inst 1993; 85: 1460–74PubMedCrossRefGoogle Scholar
  52. 52.
    Hutton J, Brown R, Borowitz M, et al. A new decision model for cost-utility comparisons of chemotherapy in recurrent metastatic breast cancer. Pharmacoeconomics 1996; 9 Suppl. 2: 8–22PubMedCrossRefGoogle Scholar
  53. 53.
    Hayman JA, Hillner BE, Harris JR, et al. Cost-effectiveness of routine radiation therapy following conservative surgery for early stage breast cancer. J Clin Oncol 1998; 16: 1022–29PubMedGoogle Scholar
  54. 54.
    Silber JH, Fridman M, Shpilsky A, et al. Modelling the cost-effectiveness of granulocyte colony-stimulating factor use in early-stage breast cancer. J Clin Oncol 1998; 16: 2435–44PubMedGoogle Scholar
  55. 55.
    Eddy DM. Screening for breast cancer. Ann Intern Med 1989; 111: 389–99PubMedGoogle Scholar
  56. 56.
    Lokich JJ, Moore CL, Anderson NR. Comparison of costs for infusion versus bolus chemotherapy administration: part two. Use of charges versus reimbursement for cost basis. Cancer 1996; 78: 300–3PubMedCrossRefGoogle Scholar
  57. 57.
    Lokich JJ, Moore CL, Anerson NR. Comparison of costs for infusion versus bolus chemotherapy administration: analysis of five standard chemotherapy regimens in three common tumors — part 1. Model project for cost based on charges. Cancer 1996; 78: 294–9PubMedCrossRefGoogle Scholar
  58. 58.
    Irvin RJ, Kuhn JG. Financial considerations in the use of adjuvant chemotherapy. Cancer Treat Res 1992; 60: 207–22PubMedCrossRefGoogle Scholar
  59. 59.
    Biermann WA, Cantor RI, Fellin FM, et al. An evaluation of the potential cost reductions resulting from the use of clodronate in the treatment of metastatic carcinoma of the breast to bone. Bone 1991; 12: S37–42PubMedCrossRefGoogle Scholar
  60. 60.
    Lawless GD, Cost-effectiveness of bone marrow transplantation. Am J Health Syst Pharm 1995; 52 Suppl. 4: S11–4PubMedGoogle Scholar
  61. 61.
    Kucharski AJ, Ghalie R, Greenstein S, et al. The clinical effectiveness and financial impact of utilizing peripheral blood progenitor cells as rescue therapy following autologous bone marrow transplant. Int J Technol Assess Health Care 1996; 12(1): 172–9PubMedCrossRefGoogle Scholar
  62. 62.
    Simon MS, Stano M, Hussein M, et al. An analysis of the cost of clinical surveillance after primary therapy for women with early stage invasive breast cancer. Breast Cancer Res Treat 1996; 37: 39–47PubMedCrossRefGoogle Scholar
  63. 63.
    Simon MS, Stano M, Severson RK, et al. Clinical surveillance for early stage breast cancer: an analysis of claims data. Breast Cancer Res Treat 1996; 40: 119–28PubMedCrossRefGoogle Scholar
  64. 64.
    Baker MS, Kessler LG, Urban N, et al. Estimating the treatment costs of breast and lung cancer. Med Care 1991; 29: 40–9PubMedCrossRefGoogle Scholar
  65. 65.
    Long SH, Gibbs JO, Crozier JP, et al. Medical expenditures of terminal cancer patients during the last year of life. Inquiry 1984; 21: 315–27PubMedGoogle Scholar
  66. 66.
    Riley GF, Potosky AL, Lubitz JD, et al. Stage of cancer at diagnosis for Medicare HMO and fee-for-service enrollees. Am J Public Health 1994; 84(10): 1598–04PubMedCrossRefGoogle Scholar
  67. 67.
    Fireman B, Quesenberry C, Somkin C, et al. Cost of care for cancer in a health maintenance organization. Health Care Financ Rev 1997; 18: 51–76PubMedGoogle Scholar
  68. 68.
    Taplin SH, Barlow W, Urban N, et al. Stage, age, comorbidity, and direct costs of colon, prostate and breast cancer care. J Natl Cancer Institute 1995; 87: 417–26CrossRefGoogle Scholar
  69. 69.
    Von Korff M, Wagner EH, Saunders K. A chronic disease score from automated pharmacy data. J Clin Epidemiol 1992; 45: 197–203CrossRefGoogle Scholar
  70. 70.
    Given BA, Given CW, Strommel M. Family and out-of-pocket costs for women with breast cancer. Cancer Pract 1994; 2: 187–93PubMedGoogle Scholar
  71. 71.
    Chang K, Nash D. The role of pharmacoeconomic evaluations in disease management. Pharmacoeconomics 1998; 14: 11–7PubMedCrossRefGoogle Scholar
  72. 72.
    Ellrodt G, Cook DJ, Lee J, et al. Evidence-based disease management. JAMA 1997; 278(20): 1687–92PubMedCrossRefGoogle Scholar
  73. 73.
    Terry K. Where disease management is paying off. Med Econ 1997; 74: 62–4PubMedGoogle Scholar
  74. 74.
    Wyatt SW, Long DM, Lee NC. State legislation related to breast cancer: 1980–1994. J Public Health Manage Pract 1996; 2(2): 64–9Google Scholar
  75. 75.
    Thompson GB, Kessler LG, Boss LP. Breast cancer screening legislation in the United States: a commentary. Am J Public Health 1989; 79: 1541–3PubMedCrossRefGoogle Scholar
  76. 76.
    Health Plan Employer Data and Information Set (HEDIS), 1999 [online]. Available from: [Accessed 1999 Dec]
  77. 77.
    Stone EM, Bailit MH, Greenberg MS, et al. Comprehensive health data systems spanning the public-private divide: the Massachusetts experience. Am J Prev Med 1998; 14: 40–5PubMedCrossRefGoogle Scholar
  78. 78.
    Byers T, Bott R, Palmer L, et al. Age is the principal determinant of the use of adjuvant cancer therapy: findings from a study of cancer care in Colorado. Denver (CO): Colorado Foundation for Medical Care, 1998Google Scholar
  79. 79.
    Crane L, Cyran E, Hopewell E. Breast Cancer Treatment Satisfaction Study. Denver (CO): Colorado Foundation for Medical Care, 1997Google Scholar
  80. 80.
    Marder RJ. Measuring the quality of care for the cancer patient. Cancer 1991; 67: 1753–8PubMedGoogle Scholar
  81. 81.
    Hillner BE. Economic and cost-effectiveness issues in breast cancer treatment. Semin Oncol 1996; 23: 98–104PubMedGoogle Scholar
  82. 82.
    American Medical Association. International classification of diseases. 9th ed. Chicago (IL): American Medical Association, 1998 JulGoogle Scholar
  83. 83.
    American Medical Association. Current procedural terminology. 4th ed. Chicago (IL): American Medical Association, 1999 OctGoogle Scholar
  84. 84.
    Bergman L, Dekker G, Kerkhoff EHM, et al. Influence of age and comorbidity on treatment choice and survival in elderly patients with breast cancer. Breast Cancer Res Treat 1991; 18: 189PubMedCrossRefGoogle Scholar
  85. 85.
    Charlson ME, Szatrowksi TP, Peterson J, et al. Validation of a combined comorbidity index. J Clin Epidemiol 1994; 47: 1245PubMedCrossRefGoogle Scholar
  86. 86.
    Fleming ST, Rastogi A, Dmitrienko A, et al. A comprehensive prognostic index to predict survival based on multiple comorbidities. Med Care 1999; 37: 601–14PubMedCrossRefGoogle Scholar
  87. 87.
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45: 613PubMedCrossRefGoogle Scholar
  88. 88.
    American College of Radiology. Breast imaging reporting and data system (BI-RADSTM). Reston (VA): American College of Radiology, 1995Google Scholar
  89. 89.
    National Comprehensive Cancer Network. NCCN practice guidelines for the treatment of breast cancer. Oncology 1999; 13(5A): 41–66Google Scholar
  90. 90.
    Burke W, Daly M, Garber J, et al. Recommendations for follow-up care of individuals with inherited predisposition to cancer. JAMA 1997; 277: 997–1003PubMedCrossRefGoogle Scholar
  91. 91.
    McGlynn EA. Choosing chronic disease measures for HEDIS: conceptual framework and review of seven clinical areas. Managed Care Q 1996; 4: 54–77Google Scholar
  92. 92.
    Mandelblatt JS, Ganz PA, Kahn KL. Proposed agenda for the measurement of quality-of-care outcomes in oncology practice. J Clin Oncol 1999; 17: 2614–22PubMedGoogle Scholar
  93. 93.
    Siu AL, McGlynn EA, Morgenstern H, et al. Choosing quality of care measures based on the expected impact of improved care on health. Health Serv Res 1992; 27: 619–50PubMedGoogle Scholar

Copyright information

© Adis International Limited 2000

Authors and Affiliations

  • K. Robin Yabroff
    • 1
  • Ruth Brown
    • 1
  • Michael Holpern
    • 1
  1. 1.MEDTAP® International, Inc.BethesdaUSA

Personalised recommendations