Cost-effectiveness of preventive strategies for women with a BRCA1 or a BRCA2 mutation

Background: For BRCA1 or BRCA2 mutation carriers, decision analysis indicates that prophylactic surgery or chemoprevention leads to better survival than surveillance alone. Objective: To evaluate the cost-effectiveness of the preventive strategies that are available to unaffected women carrying a single BRCA1 or BRCA2 mutation with high cancer penetrance. Design: Markov modeling with Monte Carlo simulations and probabilistic sensitivity analyses. Data Sources: Breast and ovarian cancer incidence and mortality rates, preference ratings, and costs derived from the literature; the Surveillance, Epidemiology, and End Results (SEER) Program; and the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services). Target Population: Unaffected carriers of a single BRCA1 or BRCA2 mutation 35 to 50 years of age. Time Horizon: Lifetime. Perspective: Health policy, societal. Interventions: Tamoxifen, oral contraceptives, bilateral salpingo-oophorectomy, mastectomy, both surgeries, or surveillance. Outcome Measures: Cost-effectiveness. Results of Base-Case Analysis: For mutation carriers 35 years of age, both surgeries (prophylactic bilateral mastectomy and oophorectomy) had an incremental cost-effectiveness ratio over oophorectomy alone of $2352 per life-year for BRCA1 and $100 per life-year for BRCA2. With quality adjustment, oophorectomy dominated all other strategies for BRCA1 and had an incremental cost-effectiveness ratio of $2281 per life-year for BRCA2. Results of Sensitivity Analysis: Older age at intervention increased the cost-effectiveness of prophylactic mastectomy for BRCA1 mutation carriers to $73 755 per life-year. Varying the penetrance, mortality rates, costs, discount rates, and preferences had minimal effects on outcomes. Limitations: Results are dependent on the accuracy of model assumptions. Conclusion: On the basis of this model, the most cost-effective strategies for BRCA mutation carriers, with and without quality adjustment, were oophorectomy alone and oophorectomy and mastectomy, respectively.