Margaret L Holland1, Alissa Huston, Katia Noyes. 1. Department of Community and Preventive Medicine, University of Rochester, Rochester, NY 14620, USA. margaret_holland@urmc.rochester.edu
Abstract
OBJECTIVES: Genetic mutations in breast cancer susceptibility genes BRCA1/2 are associated with an increased risk of breast/ovarian cancers. Cost-effective preventive measures are available for women who test positive. The objective of this study was to determine at what risk of mutation it is cost-effective to test women for BRCA1/2 mutations. METHODS: A semi-Markov model accrued costs and quality-adjusted life years (QALYs) annually from the societal perspective. The estimates of health-care costs, life expectancy, likelihood of obtaining a mastectomy or oophorectomy, and patient preferences for treatment and certainty about their BRCA1/2 status were based on the literature. RESULTS: At a 10% probability of mutation (the current guideline), the test strategy generated 22.9 QALYs over the lifetime and cost $118k, while the no-test strategy generated 22.7 QALYs and cost $117k. The incremental cost-effectiveness ratio of the test strategy was $9k and the differences between costs and effects were not substantial. The test strategy remained cost-effective to a probability of mutation of 0%, as long as utility gained from a negative test result was 0.006 or greater. These results were sensitive to the frequency of inconclusive test results and utility gain from a negative test result. CONCLUSIONS: The costs and effectiveness of both the test and no-test strategies are very similar even when there is a small probability of mutation. Current guidelines, which can be used by insurance companies to refuse coverage, could deny some women a cost-effective approach. Further research to decrease the frequency of inconclusive results could improve the cost-effectiveness of this test.
OBJECTIVES: Genetic mutations in breast cancer susceptibility genes BRCA1/2 are associated with an increased risk of breast/ovarian cancers. Cost-effective preventive measures are available for women who test positive. The objective of this study was to determine at what risk of mutation it is cost-effective to test women for BRCA1/2 mutations. METHODS: A semi-Markov model accrued costs and quality-adjusted life years (QALYs) annually from the societal perspective. The estimates of health-care costs, life expectancy, likelihood of obtaining a mastectomy or oophorectomy, and patient preferences for treatment and certainty about their BRCA1/2 status were based on the literature. RESULTS: At a 10% probability of mutation (the current guideline), the test strategy generated 22.9 QALYs over the lifetime and cost $118k, while the no-test strategy generated 22.7 QALYs and cost $117k. The incremental cost-effectiveness ratio of the test strategy was $9k and the differences between costs and effects were not substantial. The test strategy remained cost-effective to a probability of mutation of 0%, as long as utility gained from a negative test result was 0.006 or greater. These results were sensitive to the frequency of inconclusive test results and utility gain from a negative test result. CONCLUSIONS: The costs and effectiveness of both the test and no-test strategies are very similar even when there is a small probability of mutation. Current guidelines, which can be used by insurance companies to refuse coverage, could deny some women a cost-effective approach. Further research to decrease the frequency of inconclusive results could improve the cost-effectiveness of this test.
Authors: Veda N Giri; Karen E Knudsen; William K Kelly; Wassim Abida; Gerald L Andriole; Chris H Bangma; Justin E Bekelman; Mitchell C Benson; Amie Blanco; Arthur Burnett; William J Catalona; Kathleen A Cooney; Matthew Cooperberg; David E Crawford; Robert B Den; Adam P Dicker; Scott Eggener; Neil Fleshner; Matthew L Freedman; Freddie C Hamdy; Jean Hoffman-Censits; Mark D Hurwitz; Colette Hyatt; William B Isaacs; Christopher J Kane; Philip Kantoff; R Jeffrey Karnes; Lawrence I Karsh; Eric A Klein; Daniel W Lin; Kevin R Loughlin; Grace Lu-Yao; S Bruce Malkowicz; Mark J Mann; James R Mark; Peter A McCue; Martin M Miner; Todd Morgan; Judd W Moul; Ronald E Myers; Sarah M Nielsen; Elias Obeid; Christian P Pavlovich; Stephen C Peiper; David F Penson; Daniel Petrylak; Curtis A Pettaway; Robert Pilarski; Peter A Pinto; Wendy Poage; Ganesh V Raj; Timothy R Rebbeck; Mark E Robson; Matt T Rosenberg; Howard Sandler; Oliver Sartor; Edward Schaeffer; Gordon F Schwartz; Mark S Shahin; Neal D Shore; Brian Shuch; Howard R Soule; Scott A Tomlins; Edouard J Trabulsi; Robert Uzzo; Donald J Vander Griend; Patrick C Walsh; Carol J Weil; Richard Wender; Leonard G Gomella Journal: J Clin Oncol Date: 2017-12-13 Impact factor: 44.544
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