Cost-effectiveness of breast MR imaging and screen-film mammography for screening BRCA1 gene mutation carriers.
OBJECTIVE
To evaluate the clinical effectiveness and cost-effectiveness of screening strategies in which MR imaging and screen-film mammography were used, alone and in combination, in women with BRCA1 mutations.


METHODS
Because this study did not involve primary data collection from individual patients, institutional review board approval was not needed. By using a simulation model, we compared three annual screening strategies for a cohort of 25-year-old BRCA1 mutation carriers, as follows: (a) screen-film mammography, (b) MR imaging, and (c) combined MR imaging and screen-film mammography (combined screening). The model was used to estimate quality-adjusted life-years (QALYs) and lifetime costs. Incremental cost-effectiveness ratios were calculated. Input parameters were obtained from the medical literature, existing databases, and calibration. Costs (2007 U.S. dollars) and quality-of-life adjustments were derived from Medicare reimbursement rates and the medical literature. Sensitivity analysis was performed to evaluate the effect of uncertainty in parameter estimates on model results.


RESULTS
In the base-case analysis, annual combined screening was most effective (44.62 QALYs), and had the highest cost ($110973), followed by annual MR imaging alone (44.50 QALYs, $108641), and annual mammography alone (44.46 QALYs, $100336). Adding annual MR imaging to annual mammographic screening cost $69125 for each additional QALY gained. Sensitivity analysis indicated that, when the screening MR imaging cost increased to $960 (base case, $577), or breast cancer risk by age 70 years decreased below 58% (base case, 65%), or the sensitivity of combined screening decreased below 76% (base case, 94%), the cost of adding MR imaging to mammography exceeded $100000 per QALY.


CONCLUSIONS
Annual combined screening provides the greatest life expectancy and is likely cost-effective when the value placed on gaining an additional QALY is in the range of $50000-$100000.


BACKGROUND
http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09091086/-/DC1.
Lee
Janie M
JM
Department of Radiology, Institute for Technology Assessment, Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114, USA. jlee45@partners.org
McMahon
Pamela M
PM
Kong
Chung Y
CY
Kopans
Daniel B
DB
Ryan
Paula D
PD
Ozanne
Elissa M
EM
Halpern
Elkan F
EF
Gazelle
G Scott
GS
D001943:Breast Neoplasms / Q000175:diagnosis* / Q000191:economics* / Q000235:genetics*; D003362:Cost-Benefit Analysis / Q000191:economics*; D005189:False Positive Reactions; D005260:Female; D019398:Genes, BRCA1; D006801:Humans; D008017:Life Expectancy; D008279:Magnetic Resonance Imaging / Q000191:economics*; D008327:Mammography / Q000191:economics*; D008403:Mass Screening / Q000191:economics; D009010:Monte Carlo Method; D009154:Mutation; D019057:Quality-Adjusted Life Years; D012372:ROC Curve