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Cost Effectiveness of Risk-Reducing Mastectomy versus Surveillance in BRCA Mutation Carriers with a History of Ovarian Cancer

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

The appropriate management of breast cancer risk in BRCA mutation carriers following ovarian cancer diagnosis remains unclear. We sought to determine the survival benefit and cost effectiveness of risk-reducing mastectomy (RRM) among women with BRCA1/2 mutations following stage II–IV ovarian cancer.

Design

We constructed a decision model from a third-party payer perspective to compare annual screening with magnetic resonance imaging (MRI) and mammography to annual screening followed by RRM with reconstruction following ovarian cancer diagnosis. Survival, overall costs, and cost effectiveness were determined by decade at diagnosis using 2015 US dollars. All inputs were obtained from the literature and public databases. Monte Carlo probabilistic sensitivity analysis was performed with a $100,000 willingness-to-pay threshold.

Results

The incremental cost-effectiveness ratio (ICER) per year of life saved (YLS) for RRM increased with age and BRCA2 mutation status, with greater survival benefit demonstrated in younger patients with BRCA1 mutations. RRM delayed 5 years in 40-year-old BRCA1 mutation carriers was associated with 5 months of life gained (ICER $72,739/YLS), and in 60-year-old BRCA2 mutation carriers was associated with 0.8 months of life gained (ICER $334,906/YLS). In all scenarios, $/YLS and mastectomies per breast cancer prevented were lowest with RRM performed 5–10 years after ovarian cancer diagnosis.

Conclusion

For most BRCA1/2 mutation carriers following ovarian cancer diagnosis, RRM performed within 5 years is not cost effective when compared with breast cancer screening. Imaging surveillance should be advocated during the first several years after ovarian cancer diagnosis, after which point the benefits of RRM can be considered based on patient age and BRCA mutation status.

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA

    Charlotte Gamble MD, Laura J. Havrilesky MD, MHSc, Evan R. Myers MD, MPH & Noah D. Kauff MD

  2. Division of Gynecologic Oncology, Duke University Medical Center, Durham, NC, USA

    Laura J. Havrilesky MD, MHSc

  3. Duke Cancer Institute, Durham, NC, USA

    Laura J. Havrilesky MD, MHSc, Evan R. Myers MD, MPH, Junzo P. Chino MD, Jennifer K. Plichta MD, MS, P. Kelly Marcom MD, E. Shelley Hwang MD, MPH, Noah D. Kauff MD & Rachel A. Greenup MD, MPH

  4. Department of General Surgery, Division of Plastics, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, NC, USA

    Scott Hollenbeck MD

  5. Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA

    Junzo P. Chino MD

  6. Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA

    P. Kelly Marcom MD

  7. Department of Surgery, Division of Advanced Oncologic and Gastrointestinal Surgery, Duke University Medical Center, Durham, NC, USA

    Jennifer K. Plichta MD, MS, E. Shelley Hwang MD, MPH & Rachel A. Greenup MD, MPH

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  1. Charlotte Gamble MD
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  2. Laura J. Havrilesky MD, MHSc
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  3. Evan R. Myers MD, MPH
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  8. E. Shelley Hwang MD, MPH
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  9. Noah D. Kauff MD
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  10. Rachel A. Greenup MD, MPH
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Corresponding author

Correspondence to Rachel A. Greenup MD, MPH.

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Gamble, C., Havrilesky, L.J., Myers, E.R. et al. Cost Effectiveness of Risk-Reducing Mastectomy versus Surveillance in BRCA Mutation Carriers with a History of Ovarian Cancer. Ann Surg Oncol 24, 3116–3123 (2017). https://doi.org/10.1245/s10434-017-5995-z

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  • DOI: https://doi.org/10.1245/s10434-017-5995-z

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