Abstract
ObjectiveWe 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.MethodsProphylactic 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.ResultsAll 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.ConclusionAll 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.
Highlights
Breast cancer (BC) is the leading cause of years lost due to ill-health, disability or early death in women worldwide [1]
We examined the impact of the following alternative assumptions: initiation of risk reduction at 30 and 35 years instead of 40 years, immediate versus later breast reconstruction, duration of Tamoxifen’s prophylactic effect as short as only 5 years as not clearly known, duration of disutility up to 10 years for the surgical risk-reducing strategies and Ovarian cancer (OC) mortality rate reduced by 30%
All risk-reducing strategies were found to be cost-saving for the Swiss healthcare system with an increase in quality-adjusted life years (QALYs) and life years (LYs) compared to intensified surveillance (IS)
Summary
Breast cancer (BC) is the leading cause of years lost due to ill-health, disability or early death in women worldwide [1]. Germline mutations in the BRCA1- or BRCA2-gene are associated with high risk of OC and BC in affected women and characterised by early occurrence of BC (onset of disease typically after age 21 years) and OC (onset typically younger than 50 years). Women with a BRCA1 mutation have a cumulative risk of OC of 44% until age 80 years, of BC of 72% and of contralateral breast cancer (CBC) of up to 48%, depending on the age of primary BC onset [3, 4]. The cumulative risk for BRCA2 to develop OC and BC by the age of 80 years is lower at 17% and 69% [3], as is the CBC risk (relative risk of 1.6 for BRCA1 compared to BRCA2)
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