DECISION-ANALYSIS OF PROPHYLACTIC MASTECTOMY AND OOPHORECTOMY IN BRCA1-POSITIVE OR BRCA2-POSITIVE PATIENTS

Purpose: Young Ashkenazi Jewish women or those from high-risk families who test positive for BRCA1 or BRCA2 mutant genes have a significant risk of developing breast or ovarian cancer by the age of 70 years. Ma ny question whether they should have prophylactic surgical procedures, ie, bilateral mastectomy and/or oophorectomy. Methods: A Markov model was developed to determine the survival, quality of life, and cost-ef fectiveness of prophylactic surgical procedures. The probabilities of developing breast and ovarian cancer were based on literature review a mong women with the BRCA1 or BRCA2 gene and mortality rates were deter mined from Surveillance, Epidemiology, and End Results (SEER) data for 1973 to 1992. The costs for hospital and ambulatory care were estimat ed from Health Care Financing Administration (HCFA) payments in 1995, supplemented by managed care and fee-for-service data. Utility measure s for quality-adjusted life-years (QALYs) were explicity determined us ing the time-trade off method. Estimated risks for breast and ovarian cancer after prophylactic surgeries were obtained from the literature. Results: For a 30-year-old woman, according to her cancer risks, prop hylactic oophorectomy improved survival by 0.4 to 2.6 years; mastectom y by 2.8 to 3.4 years; and mastectomy and oophorectomy, by 3.3 to 6.0 years over surveillance. The QALYs saved were 0.5 for oophorectomy and 1.9 for the combined procedures in the high-risk model. Prophylactic surgeries were cost-effective compared with surveillance for years of life saved, but not for QALYs. Conclusion: Among women who test positi ve for a BRCA1 or BRCA2 gene mutation, prophylactic surgery at a young age substantially improves survival, but unless generic risk of cance r is high, provides no benefit for quality of life. Prophylactic surge ry is cost-effective for years of life saved compared with other medic al interventions that are deemed cost-effective. (C) 1998 by American Society Clinical Oncology.