A more selective approach to referring women with early stage breast cancer for costly international laboratory tests can create significant cost savings of up to 20%, and spare many women from the toxicity of chemotherapy, a recent publication from the University of Stellenbosch Business School (USB) has reported.

With more than 1.5 million cases of breast cancer diagnosed worldwide every year, it is the most common cancer that women are faced with today. More effective treatment has greatly improved survival rates but has also resulted in chemotherapy being advised to most patients, with many gaining no benefit.

The research conducted by Jaco de Jager as part of his MBA along with a team of researchers from USB, Stellenbosch University and private practise, analysed referrals of early stage breast cancer patients for the genomic test MammaPrint, which provides a genetic fingerprint of a cancerous breast tumour and accurately predicts the risk of the cancer recurring after successful surgery to remove the tumour.

Used worldwide, MammaPrint testing has identified a low-risk group for whom chemotherapy is not likely to add any further protection against future recurrence.

“A one-size-fits-all approach to breast cancer treatment is no longer acceptable in the genomic era,” said de Jager.

The test is performed centrally in The Netherlands, with a price tag in Euro, making it seemingly unaffordable in the ever-declining South African currency. In previously published work from South African and international researchers, it was reported that about half of patients with early-stage breast cancer may avoid the cost and toxicity of several months of cytotoxic chemotherapy by using MammaPrint. 

Several international studies from developed countries have shown its use to be cost-effective, but could the approximately R40 000 price tag for MammaPrint in South Africa be off-set by the approximately R107 000 cost-saving in chemotherapy if fewer patients needed to be treated?

The research team accessed anonymous clinical and pathology data of 583 patients referred for MammaPrint testing since 2007, when MammaPrint was first introduced in South Africa, and then used algorithmic models including “Predict” to classify the cases into clinically high- and low-risk.

Based on the historic use of MammaPrint in South Africa, they found that unselective referral has prioritised patients where chemotherapy might not have been indicated based on clinical grounds and that the addition of MammaPrint testing increased the total costs of care by 57%. 

“Based on clinical data, we found that performing MammaPrint testing for patients who were already at low clinical risk of needing chemotherapy adversely impacted cost effectiveness, limiting the widespread availability of the genomic test”, De Jager said.

“Overall, fewer patients would have needed chemotherapy, but the reduced cost of treating fewer patients was outweighed by the increased cost of having used MammaPrint testing in clinically low-risk patients who didn’t need the test.”

Their data was published in June in The Breast, a leading international, peer-reviewed breast cancer research journal. The research at USB is the first cost-impact analysis of genomic testing in breast cancer in South Africa.

The most important aspect of their publication showed that MammaPrint can be used in a cost-saving manner if testing is limited to only those patients where chemotherapy would be considered based on clinical grounds. This identifies about 50% of patients with a genetic low-risk result where the cost and toxicity of chemotherapy can be avoided. 

By adopting this de-escalating strategy, fewer MammaPrint tests would be performed, with a total saving of 19.5% in direct costs to medical aids. “Although not currently cost-effective with the historic referral pattern, the MammaPrint testing can be cost-effective in South African circumstances if a different approach is followed,” De Jager said.

De Jager, a pharmaceutical chemist with an MSc in Chemistry from the University of Stellenbosch, worked on a cost-benefit analysis of MammaPrint testing, from the perspective of both medical aids and patients, for his MBA research supervised by Prof Manie de Klerk of USB.

De Jager joined a research team of oncologists, pathologists and health economy academics led by oncology surgeon, Dr Ettienne Myburgh of the Panorama Centre for Surgical Oncology in Cape Town, to propose a more strategic, more cost-effective approach.

Genomic tests such as MammaPrint offer the promise of more individualised treatment and reducing uncertainty in making clinical decisions. In more developed countries they are considered cost-effective and are recommended by 93% of international breast cancer experts.

The researchers recommended that MammaPrint be used selectively in cases where a patient is (1) at high clinical risk and (2) the cancer sub-type is hormone receptor positive and human epidermal growth factor receptor-2 negative and (3) chemotherapy is being considered, and (4) where genomic testing could allow treatment de-escalation. 

They hope that managed care administrators in cancer care and medical aid schemes would use the data to adjust their approval criteria for MammaPrint testing, ensuring its sustainable use.

Together with Dr Myburgh, De Jager and Prof De Klerk, the research team consisted of private breast oncology practitioner Elizabeth Murray, Kathleen Grant of the department of biomedical sciences at Cape Peninsula University of Technology, and Maritha Kotze of the chemical pathology division in the Faculty of Medicine and Health Sciences at the University of Stellenbosch.