Cost-effectiveness of preventive strategies for women with a BRCA1 or a BRCA2 mutation.
BACKGROUND
For BRCA1 or BRCA2 mutation carriers, decision analysis indicates that prophylactic surgery or chemoprevention leads to better survival than surveillance alone.


OBJECTIVE
To evaluate the cost-effectiveness of the preventive strategies that are available to unaffected women carrying a single BRCA1 or BRCA2 mutation with high cancer penetrance.


METHODS
Markov modeling with Monte Carlo simulations and probabilistic sensitivity analyses.


METHODS
Breast and ovarian cancer incidence and mortality rates, preference ratings, and costs derived from the literature; the Surveillance, Epidemiology, and End Results (SEER) Program; and the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services).


METHODS
Unaffected carriers of a single BRCA1 or BRCA2 mutation 35 to 50 years of age.


METHODS
Lifetime.


CONCLUSIONS
Health policy, societal.


METHODS
Tamoxifen, oral contraceptives, bilateral salpingo-oophorectomy, mastectomy, both surgeries, or surveillance.


METHODS
Cost-effectiveness.


RESULTS
For mutation carriers 35 years of age, both surgeries (prophylactic bilateral mastectomy and oophorectomy) had an incremental cost-effectiveness ratio over oophorectomy alone of 2352 dollars per life-year for BRCA1 and 100 dollars per life-year for BRCA2. With quality adjustment, oophorectomy dominated all other strategies for BRCA1 and had an incremental cost-effectiveness ratio of 2281 dollars per life-year for BRCA2.


RESULTS
Older age at intervention increased the cost-effectiveness of prophylactic mastectomy for BRCA1 mutation carriers to 73,755 dollars per life-year. Varying the penetrance, mortality rates, costs, discount rates, and preferences had minimal effects on outcomes.


CONCLUSIONS
Results are dependent on the accuracy of model assumptions.


CONCLUSIONS
On the basis of this model, the most cost-effective strategies for BRCA mutation carriers, with and without quality adjustment, were oophorectomy alone and oophorectomy and mastectomy, respectively.
Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Joseph L. Mailman School of Public Health, Columbia University, and New York Presbyterian Hospital, New York, New York 10032, USA.
Kristin
K
Anderson
Judith S
JS
Jacobson
Daniel F
DF
Heitjan
Joshua Graff
JG
Zivin
Dawn
D
Hershman
Alfred I
AI
Neugut
Victor R
VR
Grann
D000328:Adult; D000367:Age Factors; D000368:Aged; D001943:Breast Neoplasms / Q000235:genetics* / Q000517:prevention & control*; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D005260:Female; D019398:Genes, BRCA1; D024522:Genes, BRCA2; D005820:Genetic Testing / Q000191:economics; D006579:Heterozygote; D006801:Humans; D008390:Markov Chains; D008408:Mastectomy / Q000191:economics*; D008875:Middle Aged; D009010:Monte Carlo Method; D009154:Mutation; D010051:Ovarian Neoplasms / Q000235:genetics* / Q000517:prevention & control*; D010052:Ovariectomy / Q000191:economics*