The budget impact of utilizing the Oncotype DX Breast Recurrence Score test from a US healthcare payer perspective

Figures & data

Figure 1. Patient flow in the budget impact model.

Table 1. Base-case parameter values, ranges, and distributions.

Parameter	Base case	DSA range	PSA SE and distribution	Source
Population parameters
Population size	1,000,000			Assumption
Percentage adult	77.80%	Not varied	Not varied	US Census Bureau^14
Percentage female	51.32%	Not varied	Not varied	US Census Bureau^14
Incidence of breast cancer	0.13%	Not varied	Not varied	SEER^19
Percentage with HR+/HER2–	69.6%	Not varied	Not varied	Nelson et al.^20
Percentage with local or regional disease	94.0%	Not varied	Not varied	DeSantis et al.^17
Percentage N0	72.7%	Not varied	Not varied	Nelson et al.^20
Percentage N0 Age ≤50 low clin. Risk	22.8%	Not varied	Not varied	Sparano et al.^21
Percentage N0 Age ≤50 high clin. Risk	8.6%	Not varied	Not varied	Sparano et al.^21
Percentage N0 Age >50 low clin. Risk	47.4%	Not varied	Not varied	Sparano et al.^21
Percentage N0 Age >50 high clin. Risk	21.2%	Not varied	Not varied	Sparano et al.^21
Percentage N1	15.4%	Not varied	Not varied	Nelson et al.^20
Percentage N1 premenopausal	33.0%	Not varied	Not varied	RxPONDER^11
Percentage N1 postmenopausal	67.0%	Not varied	Not varied	RxPONDER^11
Percentage N1mi	4.4%	Not varied	Not varied	Nelson et al.^20
Percentage chemotherapy eligible	100%	Not varied	Not varied	Assumption
Healthcare plan distribution
Commercial/ private payer	64.75%	Not varied	Not varied	US Census Bureau^14
Medicare	17.92%	Not varied	Not varied
Medicaid	17.33%	Not varied	Not varied
Breast cancer incidence rates from payer perspectives
Commercial/ private payer	0.0475%	Not varied	Not varied	US Census Bureau and SEER^14^,^19
Medicare	0.4344%	Not varied	Not varied
Medicaid	0.0475%	Not varied	Not varied
Oncotype DX RS distribution, combined N0 population
0–10	17%	Not varied	Dirichlet (1619,6711,1389)	TAILORx Sparano et al.^10
11–25	69%
26–100	14%
Oncotype DX RS distribution, age ≤50 low clinical risk
0–10	16%	Not varied	Dirichlet (348, 1626, 175)	TAILORx Sparano et al.^21
11–25	76%
26–100	8%
Oncotype DX RS distribution, age ≤50 high clinical risk
0–10	8%	Not varied	Dirichlet (64, 517, 228)	TAILORx Sparano et al.^21
11–25	64%
26–100	28%
Oncotype DX RS distribution, age >50 low clinical risk
0–10	20%	Not varied	Dirichlet (879, 3173, 414)	TAILORx Sparano et al.^21
11–25	71%
26–100	9%
Oncotype DX RS distribution, age >50 high clinical risk
0–10	14%	Not varied	Dirichlet (281, 1180, 542)	TAILORx Sparano et al.^21
11–25	59%
26–100	27%
Oncotype DX RS distribution, combined N1 population
0–13	38.1%	Not varied	Dirichlet (2147,2871,554)	RxPONDER^11
14–25	50.9%
26–100	11%
Oncotype DX RS distribution, premenopausal N1 population
0–13	34.4%	Not varied	Dirichlet (640,1015,182)	RxPONDER^11
14–25	54.6%
26–100	11%
Oncotype DX RS distribution, postmenopausal N1 population
0–13	39.9%	Not varied	Dirichlet (1492,1837,366)	RxPONDER^11
14–25	49.1%
26–100	11%
Oncotype DX RS distribution, N1mi population
0–17	58.3%	Not varied	Dirichlet (1644,998,178)	SEER Roberts et al.^22
18–30	35.4%
31–100	6.3%
Probability of chemotherapy, clinical–pathological risk alone
N0	26.5%	21.2%, 31.8%	Beta (α = 70; β = 195)	Expert opinion
N0 age ≤50 low clin. risk	24.3%	19.4%, 29.1%	Beta (α = 72; β = 226)	Expert opinion
N0 age ≤50 high clin. risk	59.6%	47.7%, 71.6%	Beta (α = 38; β = 26)	Expert opinion
N0 age >50 low clin. risk	11.4%	9.1%, 13.7%	Beta (α = 85; β = 658)	Expert opinion
N0 age >50 high clin. risk	49.3%	39.4%, 59.1%	Beta (α = 48; β = 50)	Expert opinion
N1	49.2%	39.4%, 59.0%	Beta (α = 48; β = 50)	Expert opinion
N1 premenopausal	76.4%	61.1%, 91.7%	Beta (α = 22; β = 7)	Expert opinion
N1 postmenopausal	35.7%	28.6%, 42.9%	Beta (α = 61; β = 110)	Expert opinion
N1mi (assumed equal to N0)	26.5%	21.2%, 31.8%	Beta (α = 70; β = 195)	Expert opinion
Probability of chemotherapy, N0 population by Oncotype DX RS result
0–10	4.4%	3.5%, 5.3%	Beta (α = 92; β = 1997)	Expert opinion
11–25	21.3%	17.0% 25.5%	Beta (α =75; β = 271)
26–100	88.2%	70.7%, 100.0%	Beta (α = 15; β = 2)
Probability of chemotherapy, N0 age ≤ 50 low clinical risk population by Oncotype DX RS result
0–10	2.1%	1.7%, 2.6%	Beta (α = 94; β = 4291)	Expert opinion
11–25	26.4%	21.1%, 31.7%	Beta (α = 70; β = 196)
26–100	91.1%	72.9%, 100.0%	Beta (α = 15; β = 1)
Probability of chemotherapy, N0 age ≤ 50 high clinical risk population by Oncotype DX RS result
0–10	12.9%	10.3%, 15.4%	Beta (α = 84; β = 566)	Expert opinion
11–25	48.6%	38.9%, 58.3%	Beta (α = 49; β = 52)
26–100	96.8%	77.4%, 100.0%	Beta (α =8; β = 0)
Probability of chemotherapy, N0 age > 50 low clinical risk population by Oncotype DX RS result
0–10	1.4%	1.1%, 1.7%	Beta (α = 95; β = 6531)	Expert opinion
11–25	11.4%	9.1%, 13.7%	Beta (α = 85; β = 658)
26–100	83.6%	66.9%, 100.0%	Beta (α = 15; β = 3)
Probability of chemotherapy, N0 age > 50 high clinical risk population by Oncotype DX RS result
0–10	10.0%	8.0%, 12.0%	Beta (α = 86; β = 777)	Expert opinion
11–25	28.6%	22.9%, 34.3%	Beta (α = 68; β = 171)
26–100	92.9%	74.3%, 100.0%	Beta (α = 13; β = 1)
Probability of chemotherapy, N1 population by Oncotype DX RS result
0–13	16%	Weighted average of premenopausal and post-menopausal		Expert opinion
14–25	39%
26–100	90%
Probability of chemotherapy, premenopausal N1 population by Oncotype DX RS result
0–13	43.2%	34.6% 51.9%	Beta (α = 54; β = 71)	Expert opinion
14–25	72.5%	58.0% 87.0%	Beta (α = 26; β = 10)
26–100	93.9%	75.1% 100.0%	Beta (α = 12; β = 1)
Probability of chemotherapy, postmenopausal N1 population by RS Oncotype DX result
0–13	4.3%	3.4%, 5.1%	Beta (α = 92; β = 2052)	Expert opinion
14–25	20.0%	16.0%, 24.0%	Beta (α = 77; β = 307)
26–100	88.2%	70.6%, 100.0%	Beta (α = 15; β = 2)
Probability of chemotherapy, N1mi population by Oncotype DX RS result
0–17	18%	16.1%, 19.9%	Beta (α = 296; β = 1348)	SEER Roberts et al.^22
18–30	47%	43.8%, 50.2%	Beta (α = 469; β = 529)
31–100	79%	72.9%, 85.1%	Beta (α = 141; β = 37)
N0 DRFI (by RS result)
RS 0–10 (9-year DRFI) with ET	96.8%	95.4%, 98.2%	Beta (α = 611; β = 20)	TAILORx Sparano et al.^10
RS 11–25 (9-year DRFI) with ET	94.5%	93.5%, 95.5%	Beta (α = 1964; β = 114)
RS 26–100 (9-year DRFI) with ET	59.2%	Estimated based on TAILORx DRFI with chemotherapy, adjusted using chemotherapy benefit from NSABP B-20		TAILORx and B-20 Geyer et al.^23
RS 0–10 (9-year DRFI) with CET	96.2%	Estimated based on TAILORx DRFI with ET, adjusted using HR from NSABP B-20
RS 11–25 (9-year DRFI) with CET	95.0%	Estimated based on TAILORx DRFI with ET, adjusted using HR from TAILORx		TAILORx Sparano et al.^10
RS 26–100 (9-year DRFI) with CET	86.8%	83.4%, 90.2%	Beta (α = 343; β = 52)
N1 DRFI (by RS result)
RS 0–25, premenopausal (5-year DRFI) with ET	93.9%	92.2%,95.6%	Beta (α = 780; β = 51)	RxPONDER^11
RS 0–25, postmenopausal (5-year DRFI) with ET	96.6%	95.7%,97.5%	Beta (α = 1618;β = 57)	RxPONDER^11
RS 26–100, all patients (10-year DRFI) with ET	68.6%	44.7%,83.9%	Beta (α = 14; β = 6)	TransATAC bespoke analysis (National Institute for Health and Care Excellence^24)
RS 0–25, premenopausal (5-year DRFI) with CET	96.3%	95.0%,97.6%	Beta (α = 803; β = 31)	RxPONDER^11
RS 0–25, postmenopausal (5-year DRFI) with CET	95.8%	94.8%,96.8%	Beta (α = 1605; β = 70)
RS 26–100, all patients (10-year DRFI) with CET	80.1%	Estimated using DRFI from TransATAC, adjusted using chemotherapy benefit from SWOG 8814		(Albain et al.^25; National Institute for Health and Care Excellence^24)
DRFI with CET (by RS result)
RS 0–10, N0 hazard ratio with chemotherapy	1.19	0.41, 3.51	Log normal (se = 0.55)	NSABP B-20 Geyer et al.^23
RS 11–25, N0 hazard ratio with chemotherapy	0.91	0.71, 1.180	Log normal (se = 0.13)	TAILORx^10
RS 26–100, N0 hazard ratio with chemotherapy	0.27	0.12, 0.62	Log normal (se = 0.42)	NSABP B-20 Geyer et al.^23
RS 31–100, combined N1 hazard ratio with chemotherapy	0.59	0.35, 1	Log normal (se = 0.27)	SWOG 8814 Albain et al.^25
RS 0–25, N1 premenopausal hazard ratio with chemotherapy	0.64	0.43,0.95	Log normal (se = 0.13)	RxPONDER SABCS 2021 presentation^26
RS 0–25, N1 postmenopausal hazard ratio with chemotherapy	1.12	0.82,1.52	Log normal (se = 0.18)	RxPONDER SABCS 2021 presentation^26
Probability of short-term adverse events due to chemotherapy
Febrile neutropenia	4.0%	Not varied	Not varied	Wang et al.^27
Arthralgia	2.2%
Fatigue	2.3%
Neutrophil count decreased	7.3%
White blood cell decreased	3.2%
Other transition probabilities
Probability of local recurrence prior to distant recurrence	10.5%	8.8%,12.3%	Beta (α = 86; β = 732)	Clinical expert opinion
60-month probability of AML	0.28%	0.22%, 0.34%	Beta (α = 96;β = 34127)	Petrelli et al.^28
Annual probability of CHF	0.2%	0.1%, 0.3%	Beta (α = 59; β =29467)	Wang et al.^27
Probability of death, recurrence-free	Derived from US life table	–	–	See Table S8
Annual probability of death AML	58.11%	46.49%, 69.73%	Beta (α = 62; β = 113)	NICE Technology Appraisal Guidance TA552^29
Annual probability of death CHF	14.5%	10.5%, 16.5%	Beta (α = 69.93; β = 448.07)	Wang et al.^27
Unit costs
Recurrence-free first year	$753.90	$603.12, $904.69	Gamma (θ = 96; k = 8)	Kunst et al.^30
Recurrence-free second year	$680.84	$544.68, $817.01	Gamma (θ = 96; k = 7)	Kunst et al.^30
Recurrence-free third year	$607.92	$486.33, $729.50	Gamma (θ = 96; k = 6)	Kunst et al.^30
Recurrence-free fourth year	$534.86	$427.88, $641.83	Gamma (θ = 96; k = 6)	Kunst et al.^30
Recurrence-free fifth year	$52.24	$41.79, $62.69	Gamma (θ = 96; k = 1)	Kunst et al.^30
AML	$21,349.50	$17,079.60, $25,619.40	Gamma (θ = 96; k = 222)	Wang et al.^27
CHF one-off	$35,769.44	$28,615.55, $42,923.33	Gamma (θ = 96; k = 372)	Wang et al.^27
CHF (ongoing annual cost)	$6847.73	$5,478.18, £8,217.27	Gamma (θ = 96; k = 71)	Wang et al.^27
Terminal care	$31,394.14	$25,115.31, $37,672.97	Gamma (θ = 96; k = 327)	Kunst et al.^30
Test cost Oncotype DX	$3,873	Not varied	Not varied	Medicare, 2021
One-off cost of chemotherapy, N0	$11,939.25	Not varied	Not varied	Micro costed, see Table S2
One-off cost of chemotherapy, N1	$17,127.61	Not varied	Not varied	Micro costed, see Table S2
Annual cost of endocrine therapy	$253.60	Not varied	Not varied	Micro costed, see Table S2
Distant recurrence cost	$90,055.78	Not varied	Not varied	Micro costed based on Table S4 and Table S6 and Length of treatment in Kurosky et al.^31, TA563^32 and Johnston et al.^33
Local recurrence cost	$26,235.43	Not varied	Not varied	Wang et al.^27
Febrile neutropenia	$7,765.00	Not varied	Not varied	Wang et al.^27
Arthralgia	$4,949.00
Fatigue	$105.02
Neutrophil count decreased	$7,765.00
White blood cell decreased	$7,765.00

Abbreviations. AE, adverse event; AML, acute myeloid leukemia; CET, chemo-endocrine therapy; CHF, congestive heart failure; chemotherapy; clin., clinical; DRFI, distant recurrence-free interval; HR+, hormone receptor-positive; HER2, human epidermal growth factor receptor 2; N0, node-negative; N1, node-positive; N1mi, micrometastatic; RS, risk score.

Table 2. Payer perspective conversion rates.

Conversion	Cost indices	Source
Medicare to commercial	1.27	MedPAC
Medicare to Medicaid	0.72	Henry J. Kaiser Family Foundation

Figure 2. Diagram of the budget impact model structure.

Table 3. Cost breakdown by category N0 combined population.

	Current scenario	Future scenario	Incremental budget impact	Per member per month	Per patient tested per month
Test cost	$0	$859,308	$859,308	$0.014	$64.550
Early breast cancer cost	$1,796,491	$1,852,109	$55,619	$0.001	$4.178
Recurrence-free disease management	$642,466	$645,555	$3,088	$0.000	$0.232
Early breast cancer chemo-endocrine therapy incl. AEs	$929,071	$983,864	$54,793	$0.001	$4.116
Early breast cancer endocrine therapy	$224,953	$222,691	−$2,262	$0.000	−$0.170
Breast cancer recurrence	$2,105,873	$1,472,417	−$633,457	−$0.011	−$47.584
Local recurrence	$29,260	$20,610	−$8,650	$0.000	−$0.650
Distant recurrence	$2,076,614	$1,451,807	−$624,807	−$0.010	−$46.935
AML	$4,430	$4,674	$244	$0.000	$0.018
CHF	$22,870	$24,126	$1,256	$0.000	$0.094
Terminal care	$228,073	$206,171	−$21,902	$0.000	−$1.645
Total	$4,157,737	$4,418,804	$261,067	$0.004	$19.611

Abbreviations. AE, adverse event; AML, acute myeloid leukemia; CHF, congestive heart failure.

Table 4. Cost breakdown by year N0 combined population.

	Year 0	Year 1	Year 2	Year 3	Year 4
Current scenario	$1,098,876	$535,111	$732,960	$885,582	$905,207
Test cost	$0	$0	$0	$0	$0
Chemo-endocrine therapy	$910,480	$62,347	$61,353	$60,390	$59,454
Follow-up costs	$188,396	$472,764	$671,607	$825,193	$845,753
Future scenario	$2,008,658	$453,839	$587,465	$692,384	$676,458
Test cost	$859,308	$0	$0	$0	$0
Chemo-endocrine therapy	$960,954	$62,571	$61,782	$61,006	$60,242
Follow-up costs	$188,396	$391,268	$525,684	$631,378	$616,215
Budget impact	$909,782	−$81,273	−$145,495	−$193,198	−$228,749
Test cost	$859,308	$0	$0	$0	$0
Chemo-endocrine therapy	$50,474	$223	$428	$616	$788
Follow-up costs	$0	−$81,496	−$145,923	−$193,815	−$229,538

Table 5. Cost breakdown by category N1 combined population.

	Current scenario	Future scenario	Incremental budget impact	Per member per month	Per patient tested per month
Test cost	$0	$182,027	$182,027	$0.003	$64.550
Early breast cancer cost	$643,605	$555,564	−$88,041	−$0.001	−$31.221
Recurrence-free disease management	$135,912	$136,089	$177	$0.000	$0.063
Early breast cancer chemo-endocrine therapy incl. AEs	$474,840	$379,956	−$94,884	−$0.002	−$33.648
Early breast cancer endocrine therapy	$32,853	$39,519	$6,666	$0.000	$2.364
Breast cancer recurrence	$481,387	$447,355	−$34,031	−$0.001	−$12.068
Local recurrence	$6,727	$6,261	−$466	$0.000	−$0.165
Distant recurrence	$474,659	$441,094	−$33,566	−$0.001	−$11.903
AML	$1,735	$1,384	−$352	$0.000	−$0.125
CHF	$8,958	$7,141	−$1,817	$0.000	−$0.644
Terminal care	$50,478	$48,835	−$1,643	$0.000	−$0.583
Total	$1,186,162	$1,242,305	$56,143	$0.001	$19.909

Abbreviations. AE, adverse event; AML, acute myeloid leukemia; CHF, congestive heart failure.

Table 6. Cost breakdown by year N1 combined population.

	Year 0	Year 1	Year 2	Year 3	Year 4
Current scenario	$496,140	$117,797	$163,802	$200,135	$208,288
Test cost	$0	$0	$0	$0	$0
Chemo-endocrine therapy	$456,232	$13,196	$12,972	$12,753	$12,539
Follow-up costs	$39,908	$104,601	$150,829	$187,382	$195,749
Future scenario	$589,831	$113,010	$155,372	$188,993	$195,100
Test cost	$182,027	$0	$0	$0	$0
Chemo-endocrine therapy	$367,896	$13,209	$12,997	$12,789	$12,585
Follow-up costs	$39,908	$99,801	$142,375	$176,204	$182,515
Budget impact	$93,691	−$4,788	−$8,430	−$11,143	−$13,188
Test cost	$182,027	$0	$0	$0	$0
Chemo-endocrine therapy	−$88,336	$13	$24	$35	$45
Follow-up costs	$0	−$4,800	−$8,454	−$11,178	−$13,234

Table 7. Cost breakdown by category all HR+/HER2– combined.

	Current scenario	Future scenario	Incremental budget impact	Per member per month	Per patient tested per month
Test cost	$0	$1,093,342	$1,093,342	$0.018	$59.709
Early breast cancer cost	$2,546,987	$2,527,742	−$19,244	$0.000	−$1.051
Recurrence-free disease management	$817,481	$820,820	$3,339	$0.000	$0.182
Early breast cancer chemo-endocrine therapy incl. AEs	$1,457,740	$1,431,954	−$25,786	$0.000	−$1.408
Early breast cancer endocrine therapy	$271,765	$274,969	$3,203	$0.000	$0.175
Breast cancer recurrence	$2,669,447	$1,986,419	−$683,028	−$0.011	−$37.301
Local recurrence	$37,133	$27,805	−$9,328	$0.000	−$0.509
Distant recurrence	$2,632,314	$1,958,614	−$673,700	−$0.011	−$36.792
AML	$6,422	$6,382	−$40	$0.000	−$0.002
CHF	$33,156	$32,944	−$212	$0.000	−$0.012
Terminal care	$290,767	$266,765	−$24,002	$0.000	−$1.311
Total	$5,546,778	$5,913,595	$366,816	$0.006	$20.032

Abbreviations. AE, adverse event; AML, acute myeloid leukemia; CHF, congestive heart failure.

Table 8. Cost breakdown by year all HR+/HER2– combined.

	Year 0	Year 1	Year 2	Year 3	Year 4
Current scenario	$1,659,319	$679,611	$930,821	$1,125,438	$1,151,589
Test cost	$0	$0	$0	$0	$0
Chemo-endocrine therapy	$1,419,613	$79,332	$78,069	$76,842	$75,649
Follow-up costs	$239,706	$600,279	$852,752	$1,048,596	$1,075,940
Future scenario	$2,727,855	$591,639	$773,440	$916,485	$904,175
Test cost	$1,093,342	$0	$0	$0	$0
Chemo-endocrine therapy	$1,394,807	$79,574	$78,532	$77,508	$76,502
Follow-up costs	$239,706	$512,065	$694,908	$838,977	$827,673
Budget impact	$1,068,536	−$87,972	−$157,381	−$208,952	−$247,414
Test cost	$1,093,342	$0	$0	$0	$0
Chemo-endocrine therapy	−$24,806	$241	$463	$666	$852
Follow-up costs	$0	−$88,214	−$157,844	−$209,619	−$248,267

Table 9. Clinical outcomes.

	Current scenario	Future scenario	Change
N0 number of patients assigned to chemotherapy	58	62	4
N0 number of patients with distant recurrence	9	6	−3
N1 number of patients assigned to chemotherapy	23	18	−5
N1 number of patients with distant recurrence	2	2	0
HR+/HER2– combined number of patients assigned to chemotherapy	92	92	0
HR+/HER2– combined number of patients with distant recurrence	12	9	−3

Figure 3. Tornado diagram representing the 10 parameters that had the largest impact on the model results for the N0 population.

Figure 4. Tornado diagram representing the 10 parameters that had the largest impact on the model results for the N1 population.

Figure 5. Scatter diagram, N0 population.

Figure 6. Scatter diagram, N1 population.

Table 10. Probabilistic sensitivity analysis results N0 combined population.

	Δ Cost	95% confidence interval
		Low	High
Total cost	$261,321	$29,459	$491,749
Total cost excl. assay	−$597,986	−$829,849	−$367,559
No. assigned to chemotherapy	4	−8	17
No. of distant recurrences	−3	−4	−2

Table 11. Probabilistic sensitivity analysis results N1 combined population.

	Δ Cost	95% confidence interval
		Low	High
Total cost	$53,123	−$22,174	$128,173
Total cost excl. assay	−$128,904	−$204,201	−$53,854
No. assigned to chemotherapy	−5	−8	−1
No. of distant recurrences	0	−1	0

Table 12. Scenario analysis for N0 and N1 combined populations.

Scenario	Test cost	Early BC cost	Disease recurrence cost	AML	Terminal care	Net budget impact	Difference compared with base case
N0 combined population
N0 combined population base case	$859,307.97	$55,618.55	−$633,456.59	$243.87	−$21,902.23	$261,067.11	–
Probability of chemotherapy clinical risk alone N0: 15%	$859,307.97	$424,164.19	−$760,450.75	$2,166.21	−$23,874.65	$512,493.27	$251,426.17
Probability of chemotherapy clinical risk alone N0: 35%	$859,307.97	−$216,784.75	−$539,591.35	−$1,177.00	−$20,444.36	$75,230.37	−$185,836.73
Probability of chemotherapy Oncotype DX Breast Recurrence Score Test N0 RS 11–25: 30%	$859,307.97	$239,176.45	−$639,683.03	$1,205.03	-$20,878.32	$445,346.18	$184,279.07
Probability of chemotherapy Oncotype DX Breast Recurrence Score Test N0 RS 11–25: 40%	$859,307.97	$459,744.08	−$647,164.86	$2,359.98	−$19,647.96	$666,780.39	$405,713.29
Chemotherapy benefit N0 RS >25: HR = 0.12	$859,307.97	$63,285.38	−$1,545,846.21	$243.87	−$55,254.14	−$−$677,007.59	−$938,074.70
Chemotherapy benefit N0 RS >25: HR = 0.62	$859,307.97	$51,659.45	−$148,486.82	$243.87	−$4,824.11	$759,155.90	$498,088.79
Set all test price discounts to 10%	$773,377.18	$55,618.55	−$633,456.59	$243.87	−$21,902.23	$175,136.31	−$85,930.80
Set all test price increase by 10%	$945,238.77	$55,618.55	−$633,456.59	$243.87	−$21,902.23	$346,997.90	$85,930.80
All patients commercial payer perspective	$349,364.57	$25,497.58	−$291,178.02	$111.80	−$10,040.78	$74,330.72	−$186,736.39
All patients Medicare payer perspective	$3,195,030.90	$183,607.92	−$2,096,771.38	$805.05	−$72,303.63	$1,214,513.65	$953,446.54
All patients Medicaid payer perspective	$349,364.57	$14,455.32	−$165,077.30	$63.38	−$5,692.41	$193,439.87	−$67,627.24
Cost of G-CSF reduced by 50%	$859,307.97	$42,400.71	−$633,456.59	$243.87	−$21,902.23	$247,849.26	−$13,217.85
Cost of chemotherapy reduced by 50% (including C-GSF and administration costs)	$859,308	$32,809	−$633,457	$244	−$21,902	$238,257	−$22,809.68
N1 combined population
N1 combined population base case	$182,026.72	−$88,041.26	−$34,031.31	−$351.83	−$1,642.64	$56,142.56	–
Probability of chemotherapy clinical risk alone N1 postmenopausal: 25%	$182,026.72	−$23,609.72	−$43,375.55	−$99.57	−$1,641.99	$112,784.95	$56,642.39
Probability of chemotherapy clinical risk alone N1 postmenopausal: 45%	$182,026.72	−$143,881.93	−$25,932.98	−$570.45	−$1,643.21	$7,052.48	−$49,090.07
Probability of chemotherapy Oncotype DX Breast Recurrence Score Test N1 postmenopausal RS 14–25: 30%	$182,026.72	−$60,562.05	−$35,196.72	−$243.81	−$1,543.44	$83,221.21	$27,078.65
Probability of chemotherapy Oncotype DX Breast Recurrence Score Test N1 postmenopausal RS 14–25: 40%	$182,026.72	−$33,082.85	−$36,362.12	−$135.80	−$1,444.24	$110,299.86	$54,157.30
Chemotherapy benefit N1 RS >25: HR = 0.35	$182,026.72	−$87,843.40	−$58,600.64	−$348.98	−$2,490.78	$30,940.99	−$25,201.57
Chemotherapy benefit N1 RS >25: HR = 1.00	$182,026.72	−$88,368.69	$6,351.24	−$356.56	−$236.05	$97,574.32	$41,431.77
Set all test price discounts to 10%	$163,824.05	−$88,041.26	−$34,031.31	−$351.83	−$1,642.64	$37,939.89	−$18,202.67
Set all test price increase by 10%	$200,229.40	−$88,041.26	−$34,031.31	−$351.83	−$1,642.64	$74,345.23	$18,202.67
All patients commercial payer perspective	$74,005.70	−$40,361.33	−$15,643.01	−$161.29	−$753.05	$16,253.98	−$39,888.58
All patients Medicare payer perspective	$676,801.59	−$290,641.76	−$112,645.26	−$1,161.45	−$5,422.69	$260,931.77	$204,789.21
All patients Medicaid payer perspective	$74,005.70	−$22,882.02	−$8,868.48	−$91.44	−$426.92	$41,264.57	−$14,877.99
Cost of G-CSF reduced by 50%	$182,026.72	−$61,278.96	−$34,031.31	−$351.83	−$1,642.64	$82,904.86	$26,762.30
Cost of chemotherapy reduced by 50% (including G-CSF and administration costs)	$182,027	−$47,072	−$34,031	−$352	−$1,643	$97,112	$40,969.48

Abbreviations. G-CSF, Granulocyte colony-stimulating factor; HR, hazard ratio; N0, node-negative; N1, node-positive; RS, risk score.

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