Risk-reducing mastectomy within five years of ovarian cancer diagnosis is not cost-effective compared with surveillance for patients with BRCA mutations, according to research published in Annals of Surgical Oncology (published online July 11, 2017; doi:10.1245/s10434-017-5995-z).
Mutations in the BRCA gene are associated with increased lifetime risk of developing breast and ovarian cancers. Many women who carry BRCA mutations undergo mastectomy or removal of the ovaries and fallopian tubes as initial preventive measures. However, optimal management of breast cancer risk in BRCA mutation carriers following ovarian cancer diagnosis remains unclear.
Charlotte Gamble, MD, resident physician, Duke University School of Medicine, and colleagues conducted a study to determine the survival benefit and cost-effectiveness of risk-reducing mastectomy among women with BRCA1/2 mutations following stage II-IV ovarian cancer diagnosis. Researchers compared annual screening with magnetic resonance imaging and mammography to annual screening followed by risk-reducing mastectomy with reconstruction from a third-party payer perspective. Survival, costs, and cost-effectiveness were assessed. A sensitivity analysis was performed with a $100,000 willingness-to-pay threshold.
Results of the analysis showed that the incremental cost-effectiveness ratio (ICER) per life-years saved for risk-reducing mastectomy increased with age and BRCA2 status, with greater survival benefit seen in younger patients with BRCA1 status. Risk-reducing mastectomy delayed five years in patients aged 40 years with BRCA1 status was associated with five months of life gained (ICER $72,739/life-years saved). Similarly, risk-reducing mastectomy delayed five years in patients aged 60 years with BRCA2 status was associated with 0.8 months of life gained (ICER $334,906/life-years saved).
In every scenario, dollars per life-years saved and mastectomies per breast cancer prevented were lowest with risk-reducing mastectomy performed five to 10 years after ovarian cancer diagnosis.
Researchers concluded that risk-reducing mastectomy within five years for patients with ovarian cancer and BRCA mutation status is not cost-effective 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 risk-reducing mastectomy can be considered based on patient age and BRCA mutation status,” they wrote.—Zachary Bessette