Artikel
Decision-analytic evaluation of effective and cost-effective strategies for the prevention of breast and ovarian cancer in German women with BRCA-1/2 mutations
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Veröffentlicht: | 6. März 2018 |
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Gliederung
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Background/Objective: Women with BRCA-1 or -2 gene mutations are at increased risk for developing breast and ovarian cancer. Prophylactic bilateral mastectomy (PBM) and prophylactic bilateral salpingo-oophorectomy (PBSO) may reduce the risk for developing these cancers. Aim of this study was to systematically evaluate the long-term effectiveness and cost-effectiveness of different prevention strategies compared to intensified surveillance (IS) in German women with BRCA-1/2 mutations.
Material/Methods: We developed a decision-analytic Markov model simulating breast and ovarian cancer development in BRCA-1/2 mutation carriers. German epidemiological data from German cancer registries and the Federal Statistical Office (Destatis) as well as German economic literature data were used to populate, calibrate, and validate the model. The following different strategies were compared: (1) IS, (2) PBM at age 30, (3) PBM at age 40, (4) PBSO at age 30, (5) PBSO at age 40, (6) PBM plus PBSO at age 30 or (7) PBM plus PBSO at age 40. Assessed outcomes include reduction in incidences and mortality (in %), remaining life years (LYs), quality-adjusted life years (QALYs), total costs (in €), and discounted incremental cost-effectiveness ratios (ICER). The analysis was performed from a woman’s as well as German health care system perspective, adopting a 3% annual discount rate for costs and health effects. Comprehensive deterministic sensitivity analyses were performed to assess robustness of the results.
Results: In the base-case analysis, the combination PBM plus PBSO for 30-year old German women with BRCA1/2 mutations was the most effective strategy compared to PBM or PBSO alone or intensified surveillance, followed by PBM plus PBSO at age 40. Compared to intensified surveillance the remaining life expectancy increased by 6.2 LYs (8.6 QALYs) for PBM plus PBSO at age 30 and by 5.0 LYs (7.1 QALYs) for PBM plus PBSO at age 40. In the economic analysis, PBM plus PBSO at age 30 dominated all other strategies. In the deterministic sensitivity analyses, model results were robust against variation in all relevant parameters.
Conclusion: In conclusion, based on this decision-analysis, women with BRCA1/2 mutation in Germany would benefit from PBM plus PBSO between age 30 and 40. PBM plus PBSO at age 30 may be cost-saving compared with other prevention strategies or intensified surveillance. However, individual preferences such as a woman’s family planning situation must be considered in the final decision.