Academic journal article Applied Health Economics and Health Policy

Economic Evaluation of Using a Genetic Test to Direct Breast Cancer Chemoprevention in White Women with a Previous Breast Biopsy

Academic journal article Applied Health Economics and Health Policy

Economic Evaluation of Using a Genetic Test to Direct Breast Cancer Chemoprevention in White Women with a Previous Breast Biopsy

Article excerpt

Published online: 5 March 2014

© Springer International Publishing Switzerland 2014

Abstract

Background Tamoxifen therapy reduces the risk of breast cancer but increases the risk of serious adverse events including endometrial cancer and thromboembolic events.

Objectives The cost effectiveness of using a commercially available breast cancer risk assessment test (BREVAGen(TM)) to inform the decision of which women should undergo chemoprevention by tamoxifen was modeled in a simulated population of women who had undergone biopsies but had no diagnosis of cancer.

Methods A continuous time, discrete event, mathematical model was used to simulate a population of white women aged 40-69 years, who were at elevated risk for breast cancer because of a history of benign breast biopsy. Women were assessed for clinical risk of breast cancer using the Gail model and for genetic risk using a panel of seven common single nucleotide polymorphisms. We evaluated the cost effectiveness of using genetic risk together with clinical risk, instead of clinical risk alone, to determine eligibility for 5 years of tamoxifen therapy. In addition to breast cancer, the simulation included health states of endometrial cancer, pulmonary embolism, deep-vein thrombosis, stroke, and cataract. Estimates of costs in 2012 US dollars were based on Medicare reimbursement rates reported in the literature and utilities for modeled health states were calculated as an average of utilities reported in the literature. A 50-year time horizon was used to observe lifetime effects including survival benefits.

Results For those women at intermediate risk of developing breast cancer (1.2-1.66 % 5-year risk), the incremental cost-effectiveness ratio for the combined genetic and clinical risk assessment strategy over the clinical risk assessment-only strategy was US$47,000, US$44,000, and US$65,000 per quality-adjusted life-year gained, for women aged 40-49, 50-59, and 60-69 years, respectively (assuming a price of US$945 for genetic testing). Results were sensitive to assumptions about patient adherence, utility of life while taking tamoxifen, and cost of genetic testing.

Conclusions From the US payer's perspective, the combined genetic and clinical risk assessment strategy may be a moderately cost-effective alternative to using clinical risk alone to guide chemoprevention recommendations for women at intermediate risk of developing breast cancer.

(ProQuest: ... denotes formulae omitted.)

1 Introduction

Four randomized controlled trials have demonstrated that tamoxifen reduces the risk of breast cancer in women with no personal history of breast cancer [1-4]. These trials also showed an increase in the probability of serious adverse events including endometrial cancer and thromboembolic events

Because of the trade-offs between positive and negative outcomes for tamoxifen therapy, it is important to target tamoxifen therapy towards women for whom the benefits outweigh the risks. The United States Preventative Services Task Force recommends consideration of chemoprevention for breast cancer using tamoxifen or raloxifene for women with high risk of breast cancer and low risk of adverse events [5, 6]. The American Society of Clinical Oncology recommends that tamoxifen be offered to reduce breast cancer risk in women with projected 5-year risks C1.66 % [7]. Uptake of tamoxifen for chemoprevention remains low. In a 2006 study, less than 30 % of physicians reported prescribing tamoxifen as prevention for breast cancer in the previous year [8].

The Gail model [9] and the associated Breast Cancer Risk Assessment Tool (BCRAT) [10] have been used to estimate 5-year risk in clinical trials and in computer simulations [2, 11, 12]. National Comprehensive Cancer Network guidelines recommend that women C35 years of age without a BRCA1/2, TP53, or PTEN mutation, a strong family history of breast cancer, a history of thoracic radiation, or a history of lobular carcinoma in situ should have their risk for breast cancer estimated according to the Gail model [13]. …

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