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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2009.06.021 Byline: Mary Morrogh (a), Anna Park (a), Elena B. Elkin (b), Tari A. King (a) Keywords: Nipple discharge; Clinical evaluation; Breast imaging; Breast cancer; Duct excision Abstract: For patients with nipple discharge (ND), surgical duct excision is often required to exclude underlying malignancy. Our objective was to define clinical predictors of malignancy and examine the utility of common preoperative studies. Author Affiliation: (a) Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA (b) Department of Epidemiology, Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA Article History: Received 16 March 2009; Revised 10 June 2009

Background: Androgen deprivation therapy (ADT) increases the risk for fractures in patients with prostate cancer. Objective: To assess the cost-effectiveness of measuring bone mineral density (BMD) before initiating ADT followed by alendronate therapy in men with localized prostate cancer. Design: Markov state-transition model simulating the progression of prostate cancer and the incidence of hip fracture. Data Sources: Published literature. Target Population: A hypothetical cohort of men aged 70 years with locally advanced or high-risk localized prostate cancer starting a 2-year course of ADT after radiation therapy. Time Horizon: Lifetime. Perspective: Societal. Intervention: No BMD test or alendronate therapy, a BMD test followed by selective alendronate therapy for patients with osteoporosis, or universal alendronate therapy without a BMD test. Outcome Measures: Incremental cost-effectiveness ratio (ICER), measured by cost per quality-adjusted life-year (QALY gained. Results of Base-Case Analysis: The ICERs for the strategy of a BMD test and selective alendronate therapy for patients with osteoporosis and universal alendronate therapy without a BMD test were $66 800 per QALY gained and $178 700 per QALY gained, respectively. Results of Sensitivity Analyses: The ICER for universal alendronate therapy without a BMD test decreased to $100 000 per QALY gained, assuming older age, a history of fractures, lower mean BMD before ADT, or a lower cost of alendronate. Limitations: No evidence shows that alendronate reduces actual fracture rates in patients with prostate cancer who receive ADT. The model predicted fracture rates by using data on the surrogate BMD end point. Conclusion: In patients starting adjuvant ADT for locally advanced or high-risk localized prostate cancer, a BMD test followed by selective alendronate for those with osteoporosis is a cost-effective use of resources. Routine use of alendronate without a BMD test is justifiable in patients at higher risk for hip fractures. Primary Funding Source: None.

Background Medicare managed care may offer enrollees lower out-of-pocket costs and provide benefits that are not available in the traditional fee-for-service Medicare program. However, managed care plans may also restrict provider choice in an effort to control costs. We compared rates of voluntary disenrollment from Medicare managed care to traditional fee-for-service Medicare among Medicare managed care enrollees with and without a cancer diagnosis. Methods We identified Medicare managed care enrollees aged 65 years or older who were diagnosed with a first primary breast (n = 28331), colorectal (n = 26494), prostate (n = 29046), or lung (n = 31 243) cancer from January 1, 1995, through December 31, 2002, in Surveillance, Epidemiology, and End Results (SEER) cancer registry records linked with Medicare enrollment files. Cancer patients were pair-matched to cancerfree enrollees by age, sex, race, and geographic location. We estimated rates of voluntary disenrollment to fee-for-service Medicare in the 2 years after each cancer patient's diagnosis, adjusted for plan characteristics and Medicare managed care penetration, by use of Cox proportional hazards regression. Results In the 2 years after diagnosis, cancer patients were less likely to disenroll from Medicare managed care than their matched cancer-free peers (for breast cancer, adjusted hazard ratio [HR] for disenrollment = 0.78, 95% confidence interval [Cl] = 0.74 to 0.82; for colorectal cancer, HR = 0.84, 95% Cl = 0.80 to 0.88; for prostate cancer, HR = 0.86, 95% Cl = 0.82 to 0.90; and for lung cancer, HR = 0.81, 95% Cl = 0.76 to 0.86). Results were consistent across strata of age, sex, race, SEER registry, and cancer stage. Conclusions A new cancer diagnosis between 1995 and 2002 did not precipitate voluntary disenrollment from Medicare managed care to traditional fee-for-service Medicare.

Study objectives: To develop and validate a model for estimating the risk of lung cancer death in current and former smokers. The model is intended for use in analyzing a [...]