PD06-03: Cost Effectiveness Analysis of BRCA1/2 Genetic Testing.
Authors: Li Q , Holland M , Huston A , Noyes K 
Published: June 2012

Background: Family history of breast and/or ovarian cancer is associated with an increased risk to carry a BRCA1 or BRCA2 gene mutationmutations which significantly increase a woman's risk to develop breast and/or ovarian cancer. This study examines whether BRCA1/2 genetic testing (intervention) remains cost-effective compared to no genetic testing strategy (control) from the societal and private payer perspectives given updates in healthcare practice, policy and clinical specificity of testing in the last 10 years.

Data and method: We updated a previous published semi-Markov model (Holland et al., Value in Health, 2009. 12(2): p. 207) to include new information about associated costs and treatment strategies and test specificity. The target population is 35 year old asymptomatic US women with an elevated risk of BRCA1/2 genetic mutation. The estimates of probability (prevalence, risk, preference and mortality), cost, and utility are derived from published reports and BRCA1/2 test technical documentation. We conducted the basecase cost-utility analysis and a series of sensitivity analyses by varying pretest probability of BRCA1/2 mutation, clinical sensitivity of BRCA1/2 testing, initial utility after BC diagnosis and patient preference in the first year after mastectomy, cost of BRCA1/2 testing, and out-of-pocket costs.

Results: From the societal perspective, the “no test” strategy was estimated to cost $162K and resulted in 20.2 QALY gain over a patient's lifetime. The “test” strategy was estimated to cost $172K and result in 20.5 QALY gain, resulting in the incremental cost effectiveness ratio (ICER) of $30.6K/QALY. From a private payer perspective, the ICER was $36.8K/QALY. By conducting sensitivity analyses, we concluded that the model was robust to variation in the model parameters. Within the ranges of most variable estimates, the test strategy was more cost effective compared to the no-test strategy. The initial utility after BC diagnosis (basecase value 0.75) does not impact the choice of preferred strategy (testing is always preferred). Based on the probability of mutation for women with family history (basecase value 8.7%), testing is preferred if probability is greater than 3.1%, while no testing is preferred for values &lt;3.1%. Only if cost of genetic testing is greater than $8,948 testing would it no longer be cost effective, which is however far beyond even the upper bound of cost estimate ($4,500). As long as the sensitivity of BRCA testing remains greater than 80% and initial utility after mastectomy &lt;0.9, the testing is preferred over no testing.

Discussion: The strategy of BRCA1/2 testing of women at high risk for BRCA1/2 mutations and treatment of BRCA1/2 positive women is cost-effective compared to “no genetic testing” strategy. Cost of the actual test is not a barrier to its cost-effectiveness. Despite adding MRI to breast cancer surveillance in high risk population and increases in healthcare costs, BRCA1/2 testing remains cost-effective from both the societal and from a private payer perspectives for an unaffected population with BRCA1/2 prevalence of greater than 3%.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD06-03.