title: Which screening strategy should be offered to women with BRCA1 or BRCA2 mutations? A simulation of comparative cost-effectiveness.
abstract: BACKGROUND
  There is no consensus on the most effective strategy (mammography or magnetic resonance imaging (MRI)) for screening women with BRCA1 or BRCA2 mutations. The effectiveness and cost-effectiveness of the Dutch, UK and US screening strategies, which involve mammography and MRI at different ages and intervals were evaluated in high-risk women with BRCA1 or BRCA2 mutations.
  
  
  METHODS
  Into a validated simulation screening model, outcomes and cost parameters were integrated from published and cancer registry data. Main outcomes were life-years gained and incremental cost-effectiveness ratios. The simulation was situated in the Netherlands as well as in the United Kingdom, comparing the Dutch, UK and US strategies with the population screening as a reference. A discount rate of 3% was applied to both costs and health benefits.
  
  
  RESULTS
  In terms of life-years gained, the strategies from least to most cost-effective were the UK, Dutch and US screening strategy, respectively. However, the differences were small. Applying the US strategy in the Netherlands, the costs were €43 800 and 68 800 for an additional life-year gained for BRCA1 and BRCA2, respectively. At a threshold of €20 000 per life-year gained, implementing the US strategy in the Netherlands has a very low probability of being cost-effective. Stepping back to the less-effective UK strategy would save relatively little in costs and results in life-years lost. When implementing the screening strategies in the United Kingdom, the Dutch, as well as the US screening strategy have a high probability of being cost-effective.
  
  
  CONCLUSIONS
  From a cost-effectiveness perspective, the Dutch screening strategy is preferred for screening high-risk women in the Netherlands as well as in the United Kingdom.
authors.affiliation: Department of Epidemiology, University of Groningen, University Medical Center Groningen, PO Box 30 001, 9700 RB Groningen, The Netherlands. g.h.de.bock@umcg.nl
authors.forename: G H
authors.initials: GH
authors.lastname: de Bock
authors.forename: K M
authors.initials: KM
authors.lastname: Vermeulen
authors.forename: L
authors.initials: L
authors.lastname: Jansen
authors.forename: J C
authors.initials: JC
authors.lastname: Oosterwijk
authors.forename: S
authors.initials: S
authors.lastname: Siesling
authors.forename: M D
authors.initials: MD
authors.lastname: Dorrius
authors.forename: T
authors.initials: T
authors.lastname: Feenstra
authors.forename: N
authors.initials: N
authors.lastname: Houssami
authors.forename: M J W
authors.initials: MJ
authors.lastname: Greuter
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000191:economics / Q000235:genetics*; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer / Q000191:economics / Q000379:methods*; D005260:Female; D019398:Genes, BRCA1; D024522:Genes, BRCA2; D020022:Genetic Predisposition to Disease; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000191:economics / Q000379:methods; D008327:Mammography / Q000191:economics / Q000379:methods; D008875:Middle Aged; D018803:Models, Economic; D015233:Models, Statistical; D009154:Mutation; D009426:Netherlands; D006113:United Kingdom; D014481:United States