Abstract
BackgroundWomen with mutations in BRCA1 or BRCA2 are at high risk of developing breast cancer and, in British Columbia, Canada, are offered screening with both magnetic resonance imaging (MRI) and mammography to facilitate early detection. MRI is more sensitive than mammography but is more costly and produces more false positive results. The purpose of this study was to calculate the cost-effectiveness of MRI screening for breast cancer in BRCA1/2 mutation carriers in a Canadian setting.MethodsWe constructed a Markov model of annual MRI and mammography screening for BRCA1/2 carriers, using local data and published values. We calculated cost-effectiveness as cost per quality-adjusted life-year gained (QALY), and conducted one-way and probabilistic sensitivity analysis.ResultsThe incremental cost-effectiveness ratio (ICER) of annual mammography plus MRI screening, compared to annual mammography alone, was $50,900/QALY. After incorporating parameter uncertainty, MRI screening is expected to be a cost-effective option 86% of the time at a willingness-to-pay of $100,000/QALY, and 53% of the time at a willingness-to-pay of $50,000/QALY. The model is highly sensitive to the cost of MRI; as the cost is increased from $200 to $700 per scan, the ICER ranges from $37,100/QALY to $133,000/QALY.ConclusionsThe cost-effectiveness of using MRI and mammography in combination to screen for breast cancer in BRCA1/2 mutation carriers is finely balanced. The sensitivity of the results to the cost of the MRI screen itself warrants consideration: in jurisdictions with higher MRI costs, screening may not be a cost-effective use of resources, but improving the efficiency of MRI screening will also improve cost-effectiveness.
Highlights
Women with mutations in BRCA1 or BRCA2 are at high risk of developing breast cancer and, in British Columbia, Canada, are offered screening with both magnetic resonance imaging (MRI) and mammography to facilitate early detection
MRI is more sensitive than mammography for breast cancer screening in BRCA1/2 mutation carriers, with screening trials indicating that between 89-100% of breast cancers were detected with the combination of mammography and MRI, versus 33-50% with mammography alone [10,11,12,13,14,15,16,17,18]
With the addition of MRI to annual mammography screening, 93.9% of cancers that developed by age 65 years were screen-detected, compared to 71.7% with mammography alone
Summary
Women with mutations in BRCA1 or BRCA2 are at high risk of developing breast cancer and, in British Columbia, Canada, are offered screening with both magnetic resonance imaging (MRI) and mammography to facilitate early detection. Cost-effectiveness ratios are sensitive to the unit cost of an MRI screening test [21,22,23] and to the breast cancer risk in the population being screened [20,24]. The objective of this study is to estimate the costeffectiveness of annual mammography plus MRI screening for breast cancer in BRCA1/2 mutation carriers, as compared to screening with mammography alone, from the perspective of the British Columbia healthcare system, using local cost and outcomes data
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