Should women with a BRCA1/2 mutation aged 60 and older be offered intensified breast cancer screening? – A cost-effectiveness analysis. (June 2019) - Phi, Xuan-Anh
Abstract: Objectives: This study aimed to investigate the cost-effectiveness of intensified breast cancer (BC) screening for women with a BRCA1/2 mutation aged 60–74. Simulated strategies were: (0) annual mammography as reference, (1) alternating annual mammography and MRI for women with dense breasts only; (2) addition of annual MRI for women with dense breasts only; (3) addition of annual MRI for all women. Materials and methods: A validated micro-simulation model of invasive BC was updated and validated for interval BC rates and tumor size distribution. Incremental cost-effectiveness ratios (ICER) of all three intensified strategies were compared to the next best strategy and stratified for BRCA1 and BRCA2. Discount rates for costs and life years gained (LYG) were 1.5% and 4% for the Dutch situation; 3% and 3% for international comparison. A threshold of €20, 000 per LYG was applied. Results: All intensified strategies showed more detected BCs and LYG, reduced BC deaths, and increased false positives. The Dutch discounted ICER of intensified strategy 1 compared to annual mammography was €38, 000 per LYG in BRCA1 mutation carriers and €18, 000 per LYG in BRCA2 mutation carriers. Further intensified strategies showed an ICER above the threshold when compared to this strategy. With international discount rate, the ICERs of all intensified strategies were above the threshold. Conclusion: Of the three alternative strategies, only alternating annual MRI and mammography for BRCA2 mutation carriers and dense breasts aged 60–75 is cost-effective compared to annual mammography. For BRCA1 mutation carriers, none of the alternative strategies is cost-effective compared to the next best strategy. Highlights: This study uses SIMRISC model-a validated breast cancer micro-simulation model. For BRCA2 mutation carriers alternating annual MRI and mammography is cost-effective. For BRCA1 mutation carriers intensified screening strategies are not cost-effective. Different screening strategies based on BRCA mutation type should be considered.