Cost analysis of using Magee scores as a surrogate of Oncotype DX for adjuvant treatment decisions in women with early breast cancer

Breast cancer is the most common cancer in women worldwide. Most current guidelines recommend using multigene profiling assays to aid the decision on the addition of chemotherapy to adjuvant hormone therapy for women who present with early‐stage, hormone receptor‐positive, HER2‐negative disease. One of these assays is the Oncotype DX, which predicts the disease recurrence risk and adjuvant chemotherapy benefits. Given its high cost, there is an economic incentive to evaluate its surrogates, such as the Magee equations. We assessed health system costs associated with the use of the Magee scores. A probabilistic decision tree was used to calculate the difference in mean health system costs based on data obtained from a randomized trial and the published literature. Costs were calculated from a perspective of Canada's publicly funded health care system. A series of sensitivity analysis was conducted to assess the robustness of the study findings. The Magee equations were associated with a total cost savings of C$100 per patient (95% CI, ?C$3068 to C$5022) compared with standard of care. The difference in costs was highly sensitive to the extent that the Magee scores could reduce the frequency of adjuvant chemotherapy and Oncotype DX requests.     

Follow-up of rape victims in a family practice setting.

Health care for rape victims traditionally has been crisis oriented, focused solely upon the victim, and provided either by a gynecologist or psychiatrist. A family practice health team, working in a county hospital, offered rape victims and their families crisis counseling in the emergency room, and follow-up care in a family practice clinic. Follow-up of victims markedly increased from 8% before initiation of the program to 86% afterward. Family members of more than half of the victims seen on follow-up received treatment. A wide range of health needs of both victims and their families, not identified in the emergency room, was identified on follow-up visits. In this way emergency care of the rape victim often became an entry point into the health care system. Rape must be viewed as a family's as well as victim's health problem, often demanding a broader service than can be offered by a gynecologist or psychiatrist alone.     

Increased competition may promote species coexistence

It is a mainstay of community ecology that local exclusion of species will result if competitive pressures become too large. The pattern of exclusion may be complicated, but the qualitative orthodoxy has changed little since the pioneering work of Lotka, Volterra, and Gause--no two species can occupy the same niche. Stated in a more precise form, the higher the intensity of interspecific competition in an assemblage of species, the fewer the number of species that can coexist in perpetuity. We suggest that this orthodoxy results from "linear" thinking, and that if the classical equations are formulated more realistically with attendant nonlinearities, the orthodoxy breaks down and higher levels of competition may actually increase the likelihood that species will avoid competitive exclusion. Furthermore, this increased probability of coexistence at higher levels of competition is accompanied by characteristic dynamic patterns: (i) at lower levels of competition, after all extinction events have occurred, remaining species follow irregular chaotic patterns; (ii) at higher levels of competition, when most species coexist, all species are entrained in a single large limit cycle; (iii) the transient behavior appears to correspond to a special case of chaos, uniform phase chaotic amplitude.