Thus, the committee agreed that the HCFA data banks should be used to develop preliminary information on the costs and effectiveness of prevention, diagnosis, treatment, and rehabilitation of breast cancer. The committee further endorsed the general concept that analysis of variations in patterns of care and outcomes by geographic area, by institution, by type of provider or practitioner, and by other factors should be carried out as part of any effectiveness research program. Finally, the committee believed that separate studies to determine the content and outcomes of care provided to the Medicare population will be of particular value, especially if those analyses can help to advance the understanding of the role and results of prevention strategies, to clarify whether treatments offered to older women differ systematically from those offered to younger women, and to identify preferred patient management regimens.

SELECTING PATIENT MANAGEMENT ISSUES

Several factors figure in selecting key patient management issues in breast cancer for effectiveness research, especially for elderly women. These factors are not equally well documented in the clinical, research, or health policy literature, but the committee believed that all are sufficiently important to be taken into account as specific study topics are developed. They include:

  • Epidemiologic aspects of breast cancer among elderly women (e.g., higher or lower prevalence of more advanced disease in particular subgroups);

  • Important health status and quality-of-life burdens of the illness on elderly women;

  • Different treatment options characterized by, for instance, whether alternative therapies have different likelihoods of prolonging survival, producing major impairment and disability, or improving the woman’s physical functioning, emotional well-being, and independence;

  • High degree of professional and clinical uncertainty or dispute about alternative strategies for managing the care of breast cancer in elderly patients, especially when different types of treatment modalities have been found to produce equivalent results (e.g., in terms of survival) or trade-offs among outcomes (e.g., in terms of treatment-induced and disease-related complications or costs);

  • Substantial variation across geographic areas in the per-person use of services for breast cancer, including screening modalities; that is, variation beyond that apparently explained by differences in patient characteristics or health resources in the areas;

  • Substantial variation across geographic areas or institutions in the



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