研究目的
隨著更年期後女性的數量增加，有更年期不適症狀的婦女也隨之增加，許多女性使用荷爾蒙替代療法(HRT)的藥物，然而使用HRT會提高罹患乳癌的相對風險，因此要透過甚麼樣的方式來減少乳癌發生的機率，或是及早發現乳癌，並且及早治療，就成為了目前的當務之急。乳房攝影可以有效降低乳癌死亡率以及晚期乳癌發生率，是目前最有效的篩檢方式之一。因此，本研究探討更年期後使用HRT的女性進行每年一次乳房攝影的成本效果以及分析。這是首篇針對該特定族群進行成本效果分析的研究，希望能為使用HRT的更年期婦女的乳癌防治提供決策參考，並提供後續篩檢頻率的考量依據。
研究方法
本研究以醫療服務提供者的觀點，進行馬可夫模型(Markov Model)微觀模擬(Microsimulation)，評估每年一次的乳房攝影篩檢相比於無提供篩檢計畫之成本效果，研究模擬對象為45歲停經後使用HRT的婦女，時間範圍為20年。成本考量包括乳房篩檢以及乳癌治療之直接醫療成本，效果則以生活品質調整年(Quality Adjusted Life Years, QALYs)估計。資料來源包含近年來自歐美國家當地研究的文獻與專家意見。本模型將健康狀態區分為健康，不同期別的乳癌、康復者、復發與死亡等13種，並以每年為一周期，模擬100,000次，分析參與篩檢計畫與無參與篩檢計畫兩族群之遞增成本效果比(ICER)，接著進行單維敏感度分析以及機率性敏感度分析。
研究結果
本研究結果顯示參與篩檢組之累積成本為30,133.63美元，無提供篩檢組為26,576.96美元；參與篩檢組之累積效用為11.49QALYs，無提供篩檢組之累積效用為11.03QALYs；參與篩檢組之遞增成本為6.343.49美元，參與篩檢組遞增效用為0.47QALYs，參與篩檢組遞增成本效果比為7,632.82美元/QALY，遠低於所設定之支付意願，代表參與篩檢組相比於無提供篩檢組，在每年定期篩檢的情況下，更具有成本效果。單維敏感度分析結果發現，對ICER值影響最顯著的5個變項依序如下：診斷費用、乳癌發生率、乳房攝影特異性、乳房攝影費用、Stage0之初期治療費。機率性敏感度分析結果發現，在每年進行一次乳房攝影篩檢的計畫下，相比於無提供篩檢計畫者，將有100%的機率符合成本效果。
結論與建議
針對更年期後使用HRT之女性族群，參與每年一次的乳房篩檢計畫，相比於無提供篩檢計畫，更具有成本效果，因此有更年期後不適症之女性，可以參考醫師建議，決定是否要使用HRT並參與定期篩檢，以緩解更年期不適症所帶來的痛苦，並且降低HRT副作用的嚴重性。

Objective:
With an increasing number of women experiencing menopause and the associated rise in menopausal symptoms, many women resort to hormone replacement therapy (HRT). However, the use of HRT has been linked to an elevated relative risk of developing breast cancer. Therefore, it is crucial to develop strategies to facilitate early detection and ensure timely treatment. Mammography screening has been proven to be an effective method in reducing breast cancer mortality and the incidence of late-stage breast cancer. This study aims to analyze the cost-effectiveness of annual mammography screening for postmenopausal women on HRT. It is the first cost-effectiveness analysis targeting this specific population, with the goal of providing decision-making guidance for breast cancer prevention and screening frequency considerations.

Methods:
From a healthcare provider perspective, this study employed a Markov microsimulation model to evaluate the cost-effectiveness of annual mammography screening compared to no screening program for postmenopausal women aged 45 years and older on HRT. The time horizon was set to 20 years. Direct medical costs associated with mammography screening and breast cancer treatment were considered horizon was set to 20 years, while the outcomes were measured in quality-adjusted life years (QALYs). Both accumulative costs and outcomes over 20 years were converted to present values with a discount rate of 3% in the base-case analysis. Data sources included recent literature from local studies in European and American countries, as well as expert opinions. The model classified health states into 13 categories, including health, different stages of breast cancer, recovery, recurrence, and death. Monte Carlo simulation was performed with 100,000 iterations to analyze the incremental cost-effectiveness ratio (ICER) between the screening and non-screening groups. Additionally, one-way sensitivity analysis and probabilistic sensitivity analysis were conducted.

Results:
The incremental cost for the screening group was estimated to be $6,343.49 USD per person, with an estimated incremental utility of 0.47 QALYs per person for a base-case result. The incremental cost-effectiveness ratio (ICER) for the screening group compared to the non-screening group was $7,632.82 USD per QALY, which was below the predefined willingness-to-pay (WTP) threshold of $50,000 USD. This indicates that participating in the screening program, with annual mammography regularly is more cost-effective than those without providing screening.

The results of the one-way sensitivity analysis identified the following five variables with the most significant impact on the ICER: diagnostic costs, breast cancer incidence rate, mammography specificity, mammography costs, and early-stage treatment costs for Stage 0. The probabilistic sensitivity analysis revealed a 100% of probability favoring the annual mammography strategy. Both sensitivity analyses support the robustness of the base-case results.

Conclusion:
For postmenopausal women on HRT, participating in an annual mammography screening program is more cost-effective than not providing screening. Therefore, women with menopausal symptoms and taking HRT are encouraged to take annual mammography reduce the severity and the economic burden from the possible risk of breast cancer.

目錄

論文審定書 i
中文摘要 ii
英文摘要 iii
目錄 v
圖次 vii
表次 viii
第壹章 緒論 1
第一節 研究背景 1
第二節 研究動機 2
第三節 研究目的 2
第四節 名詞解釋 3
第貳章 文獻探討 8
第一節 乳癌概述 8
一、 乳癌簡介 8
二、 乳癌的趨勢 8
三、 乳癌分期 9
第二節 乳癌與HRT之間的關聯性 10
一、 乳癌的危險因子 10
二、 荷爾蒙替代療法如何影響乳癌 10
第三節 乳房攝影在荷爾蒙替代療法使用者身上的成效 11
第四節 乳房攝影之成本效果分析 11
第參章 研究方法 18
第一節 研究模型與架構 18
第二節 研究假說 19
第三節 本研究決策模型 20
第四節 資料蒐集 26
第五節 成本效果分析 28
一、 基本案例分析(Base-Case Analysis) 28
二、 參數之現值及折現率設定與計算 29
三、 支付意願(Willing To Pay, WTP) 29
四、 敏感度分析(Sensitivity Analysis) 29
五、 其他假設分析(What-if Analysis) 30
第肆章 研究結果 32
第一節 研究模型參數 32
第二節 成本效果基礎分析結果 42
第三節 敏感度分析結果 44
一、 單維敏感度分析 44
二、 機率性敏感度分析 46
第伍章 討論與研究限制 51
第一節 討論研究目的與研究假說 51
一、 成本效果分析與假說之結果討論 52
二、 敏感度分析與假說之結果討論 53
第二節 與其他文獻之比較 53
第三節 研究中設定與假設之討論 55
第四節 研究結果之應用 58
第五節 研究限制 62
第陸章 結論與未來方向 64
第一節 結論 64
第二節 研究貢獻 64
一、學術層面 64
二、醫療政策層面 65
三、醫療提供者 65
四、篩檢者及家屬層面 65
第三節 未來方向 66
參考文獻 68


圖次
第參章
圖3-1. 研究架構 19
圖3-2. 本研究之馬可夫模型 21
圖3-3. 馬可夫決策模型架構圖 24
圖3-4. 遞增成本效果比值(ICER)之計算公式 29
第肆章
圖4-1. 本研究基礎分析之成本效果平面 (COST-EFFECTIVENESS PLANE) 43
圖4-2. ICER單維敏感度分析之龍捲風圖 45
圖4-3. 機率性敏感度分析之模擬結果散布圖 47
圖4-4. 機率性敏感度分析之模擬結果ICER分布圖 48
圖4-5. 成本效果可接受曲線 49

 
表次
第貳章
表2-1. AJCC 8TH 乳癌分期表 9
表2-2. 過去成本效果文獻彙整 16
第參章
表3-1. 本研究所需蒐集的變數整理 28
第肆章
表4-1. 本研究決策分析模之轉換機率參數估計 35
表4-2. 本研究決策分析模式之成本參數估計 39
表4-3. 本研究決策分析模型之效用參數估計 41
表4-4. 不同周期成本效果分析結果 50
第伍章
表5-1. 研究目的與研究假說之結果 51

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