Cost–utility analysis of risk-reducing strategies to prevent breast and ovarian cancer in BRCA-mutation carriers in Switzerland

Abstract

Objective We aimed to identify the most cost-effective of all prophylactic measures available in Switzerland for women not yet affected by breast and ovarian cancer who tested positive for a BRCA1/2 mutation. Methods Prophylactic bilateral mastectomy (PBM), salpingo-oophorectomy (PBSO), combined PBM&PBSO and chemoprevention (CP) initiated at age 40 years were compared with intensified surveillance (IS). A Markov model with a life-long time horizon was developed from the perspective of the Swiss healthcare system using mainly literature-derived data to evaluate costs, quality-adjusted life years (QALYs) and survival. Costs and QALYs were discounted by 3% per year. Robustness of the results was tested with deterministic and probabilistic sensitivity analyses. Results All prophylactic measures were found to be cost-saving with an increase in QALYs and life years (LYs) compared to IS. PBM&PBSO were found to be most cost-effective and dominated all other strategies in women with a BRCA1 or BRCA2 mutation. Lifetime costs averaged to 141,293 EUR and 14.5 QALYs per woman with a BRCA1 mutation under IS, versus 76,639 EUR and 19.2 QALYs for PBM&PBSO. Corresponding results for IS per woman with a BRCA2 mutation were 102,245 EUR and 15.5 QALYs, versus 60,770 EUR and 19.9 QALYs for PBM&PBSO. The results were found to be robust in sensitivity analysis; no change in the dominant strategy for either BRCA-mutation was observed. Conclusion All more invasive strategies were found to increase life expectancy and quality of life of women with a BRCA1 or BRCA2 mutation and were cost-saving for the Swiss healthcare system compared to IS.

Cost-Effectiveness of Risk-Reducing Surgery for Breast and Ovarian Cancer Prevention: A Systematic Review

“…For BRCA1 PV carriers, two studies found that RRSO at the age of 35 was the most cost-saving [ 28 ] or cost-effective, with an ICUR of $2101/QALY [ 29 ], compared to other surgical prevention strategies (RRM or combined RRM and RRSO), chemoprevention (tamoxifen/oral contraceptives) and surveillance. Three other studies found that combined RRM and RRSO at the age of 40 [ 41 ], or combined RRM at the age of 35 with RRSO at the age of 45 [ 53 ] was the most cost-saving; RRM at the age of 30 with RRSO at the age of 35 was the most cost-effective, with an ICER of $835/LYG [ 47 ]. For BRCA2 PV carriers, two studies found that combined RRM and RRSO at the age of 35 was the most cost-effective, with an ICUR of $3125/QALY [ 28 ], ant that combined RRM and RRSO at the age of 40 was the most cost-saving [ 41 ], compared with other preventive strategies or surveillance.…”

“…Three other studies found that combined RRM and RRSO at the age of 40 [ 41 ], or combined RRM at the age of 35 with RRSO at the age of 45 [ 53 ] was the most cost-saving; RRM at the age of 30 with RRSO at the age of 35 was the most cost-effective, with an ICER of $835/LYG [ 47 ]. For BRCA2 PV carriers, two studies found that combined RRM and RRSO at the age of 35 was the most cost-effective, with an ICUR of $3125/QALY [ 28 ], ant that combined RRM and RRSO at the age of 40 was the most cost-saving [ 41 ], compared with other preventive strategies or surveillance. A study reported that RRSO at the age of 40 was the most cost-effective, with an ICUR of $5535/QALY [ 29 ], and another one found that RRM at the age of 35 was the most cost-saving [ 53 ].…”

“…The shift in practice towards performing MRI for BRCA1/2 PV carriers was considered in 6/8 of the studies included, while the cost-effectiveness of RRM varied when compared to surveillance. Three studies [ 41 , 45 , 53 ] reported that RRM was cost-effective or cost-saving compared to MRI-based screening. However, Grann et al [ 29 ] found that mammography and MRI for BRCA1/2 PV carriers was associated with highest costs, while its cost-effectiveness varied due to different disutility values when compared to RRM.…”

Risk-Reducing Breast and Gynecological Surgery for BRCA Mutation Carriers: A Narrative Review

“…BRCA1 gene mutations cause familial breast-ovarian cancer-1 (BROVCA1), and BRCA2 gene mutations cause familial breast-ovarian cancer-2 (BROVCA2). Up until the age of 80, women who are BROVCA1-sensitive have a cumulative risk of 72% for breast cancer and 44% for ovarian cancer [ 8 , 9 , 10 ]. However, BROVCA2-sensitive women have a cumulative risk of 17% for ovarian cancer and 69% for breast cancer at the same age [ 8 , 10 ].…”

“…Up until the age of 80, women who are BROVCA1-sensitive have a cumulative risk of 72% for breast cancer and 44% for ovarian cancer [ 8 , 9 , 10 ]. However, BROVCA2-sensitive women have a cumulative risk of 17% for ovarian cancer and 69% for breast cancer at the same age [ 8 , 10 ].…”