title: Cost-effectiveness of contralateral prophylactic mastectomy versus routine surveillance in patients with unilateral breast cancer.
abstract: OBJECTIVE
  Contralateral prophylactic mastectomy (CPM) rates in women with unilateral breast cancer are increasing despite controversy regarding survival advantage. Current scrutiny of the medical costs led us to evaluate the cost-effectiveness of CPM versus routine surveillance as an alternative contralateral breast cancer (CBC) risk management strategy.
  
  
  METHODS
  Using a Markov model, we simulated patients with breast cancer from mastectomy to death. Model parameters were gathered from published literature or national databases. Base-case analysis focused on patients with average-risk breast cancer, 45 years of age at treatment. Outcomes were valued in quality-adjusted life-years (QALYs). Patients' age, risk level of breast cancer, and quality of life (QOL) were varied to assess their impact on results.
  
  
  RESULTS
  Mean costs of treatment for women age 45 years are comparable: $36,594 for the CPM and $35,182 for surveillance. CPM provides 21.22 mean QALYs compared with 20.93 for surveillance, resulting in an incremental cost-effectiveness ratio (ICER) of $4,869/QALY gained for CPM. To prevent one CBC, six CPMs would be needed. CPM is no longer cost-effective for patients older than 70 years (ICER $62,750/QALY). For BRCA-positive patients, CPM is clearly cost-effective, providing more QALYs while being less costly. In non-BRCA patients, cost-effectiveness of CPM is highly dependent on assumptions regarding QOL for CPM versus surveillance strategy.
  
  
  CONCLUSIONS
  CPM is cost-effective compared with surveillance for patients with breast cancer who are younger than 70 years. Results are sensitive to BRCA-positive status and assumptions of QOL differences between CPM and surveillance patients. This highlights the importance of tailoring treatment for individual patients.
authors.affiliation: Department of Surgery, Mayo Clinic, 200 First St SW, Rochester MN, USA.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Zendejas
authors.forename: James P
authors.initials: JP
authors.lastname: Moriarty
authors.forename: Jamie
authors.initials: J
authors.lastname: O'Byrne
authors.forename: Amy C
authors.initials: AC
authors.lastname: Degnim
authors.forename: David R
authors.initials: DR
authors.lastname: Farley
authors.forename: Judy C
authors.initials: JC
authors.lastname: Boughey
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000191:economics / Q000517:prevention & control* / Q000601:surgery*; D015986:Confounding Factors, Epidemiologic; D003362:Cost-Benefit Analysis; D004180:Direct Service Costs; D005260:Female; D006801:Humans; D008390:Markov Chains; D015411:Mastectomy, Modified Radical / Q000191:economics*; D008875:Middle Aged; D057240:Patient Preference; D011159:Population Surveillance; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D012107:Research Design; D018570:Risk Assessment; D012307:Risk Factors; D055502:Secondary Prevention / Q000191:economics* / Q000379:methods; D014481:United States