Breast Cancer: Setting Priorities for Effectiveness Research

Report of a Study by a Committee of the

INSTITUTE OF MEDICINE

Division of Health Care Services

Kathleen N.Lohr, editor

NATIONAL ACADEMY PRESS
Washington, D.C.
1990



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Breast Cancer: Setting Priorities for Effectiveness Research Breast Cancer: Setting Priorities for Effectiveness Research Report of a Study by a Committee of the INSTITUTE OF MEDICINE Division of Health Care Services Kathleen N.Lohr, editor NATIONAL ACADEMY PRESS Washington, D.C. 1990

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Breast Cancer: Setting Priorities for Effectiveness Research NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This workshop was supported by the Health Care Financing Administration, U.S. Department of Health and Human Services, under Basic Ordering Agreement Contract No. 500–89–0008. Library of Congress Catalog Card No. 89–64426 International Standard Book Number 0-309-04226-7 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, NW Washington, DC 20418 S102 Printed in the United States of America

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Breast Cancer: Setting Priorities for Effectiveness Research INSTITUTE OF MEDICINE Division of Health Care Services HCFA Effectiveness Initiative Breast Cancer Research Workshop Committee KENNETH I.SHINE, Chair, Dean, School of Medicine, University of California, Los Angeles MARTIN D.ABELOFF, Professor and Associate Director, Johns Hopkins Oncology Center, Baltimore, Maryland BARBARA DANOFF FOWBLE, Professor, Department of Radiologic Oncology, Hospital of the University of Pennsylvania, Philadelphia SHELDON GREENFIELD, Senior Scientist, Institute for the Improvenment of Medical Care and Health, New England Medical Center, Boston, Massachusetts MAUREEN M.HENDERSON, Head, Cancer Prevention Research Center, Fred Hutchinson Cancer Research Center, Seattle, Washington VALERIE P.JACKSON, Associate Professor of Radiology, Department of Radiology, Indiana University School of Medicine, Indianapolis EMMETT B.KEELER, Senior Mathematician, Economics Department, The RAND Corporation, Santa Monica, California LUELLA KLEIN, Professor and Chair, Department of Gynecology and Obstetrics, Emory University, Atlanta, Georgia |MARY K.KNOBS, Section on Medical Oncology, Yale Medical Center, New Haven, Connecticut BARBARA J.MCNEIL, Head, Department of Health Care Policy, Harvard Medical School, Boston, Massachussettes JOHN S.MEYER, Department of Pathology, St. Luke Hospital, Chesterfield, Missouri MONICA MORROW, Associate Professor of Surgery, The University of Chicago, Illinois DAVID G.MURRAY, Professor of Orthopedic Surgery, Health Services Center, State University of New York, Syracuse ALAN R.NELSON, Associate, Memorial Medical Center, Salt Lake City, Utah J.SANFORD SCHWARTZ, Professor, General Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia G.RICHARD SMITH, Associate Professor of Psychiatry, Department of Psychiatry, University of Arkansas for the Medical Sciences, Little Rock HAROLD G.SOX, Professor and Chairman, Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire WILLIAM C.WOOD, Medical Director, Cancer Center, Massachusetts General Hospital, Boston

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Breast Cancer: Setting Priorities for Effectiveness Research STUDY STAFF Division of Health Care Services KARL D.YORDY, Director KATHLEEN N.LOHR, Senior Professional Associate KIM HEITHOFF, Research Assistant Division of Health Promotion and Disease Prevention RICHARD A.RETTIG, Senior Staff Officer MARIA ELENA LARA, Program Officer

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Breast Cancer: Setting Priorities for Effectiveness Research Acknowledgments The contributions of several members of the Institute of Medicine staff deserve special mention. Among them are H.Donald Tiller, administrative associate, and Theresa Nally, project secretary. Maria Elena Lara was diligent in reviewing workshop materials and earlier drafts of this report, and Kim Heithoff contributed greatly to the smooth logistics of the committee’s homework exercise and the workshop meeting. Richard A.Rettig and Karl D.Yordy provided steady support and leadership throughout the entire project. The committee is particularly indebted to several of the anonymous reviewers of the draft of this report for comments and suggestions that have been incorporated into the text. Support for this study was provided by the U.S. Department of Health and Human Services, Health Care Financing Administration. We particularly wish to acknowledge the unflagging assistance and guidance of the government’s project officer, John Spiegel, of the Health Standards and Quality Bureau.

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Breast Cancer: Setting Priorities for Effectiveness Research Contents     ACKNOWLEDGMENTS   v     SUMMARY   1     INTRODUCTION   5      Effectiveness Initiative,   5      The IOM Clinical Workshop,   6      Condition-Specific Research Workshops,   7     THE KNOWLEDGE BASE FOR KEY CLINICAL ISSUES IN BREAST CANCER   9      Detection and Diagnosis,   9      Staging,   10      Surgical and Other Treatment Options in Breast Cancer,   12     FACTORS IMPORTANT FOR THE SELECTION OF KEY PATIENT MANAGEMENT ISSUES AND RELATED RESEARCH ACTIVITIES   19      Selecting Patient Management Issues,   20      Selecting Research Topics and Activities,   21     KEY PATIENT MANAGEMENT TOPICS FOR EFFECTIVENESS RESEARCH IN BREAST CANCER   24      Preliminary Discussion and Selection of Major Topics,   24      Summary of Recommendations,   25      Methods Issues,   28      Patient Management Topics,   31      Age,   37     CONCLUSIONS   39     BIBLIOGRAPHY   41 APPENDIX A:   Background and Conduct of the Workshop   45

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