To identify and evaluate studies addressing the effectiveness and cost-effectiveness of cancer risk management interventions for BRCA1/2 carriers.
A systematic search of academic databases and grey literature was performed for decision analytic models and economic evaluations of breast and ovarian cancer risk management in BRCA1/2 mutation carriers, including any combination of surveillance, prophylactic oophorectomy or mastectomy, or risk reducing medication.
Thirty-two studies were included from 2504 identified, comprising 8 decision models and 24 economic evaluations. Eleven were concerned primarily with the utility of cancer genetic services or performing genetic testing, with limited modelling of downstream risk management intervention pathways. Prophylactic bilateral salpingo-oophorectomy (19/32), mammography (19/32) and prophylactic mastectomy (16/32) were the most frequently evaluated interventions, and breast MRI featured in publications from 2005 only (12/24). Risk reducing surgery, namely bilateral salpingo-oophorectomy with or without bilateral prophylactic mastectomy, was consistently the most cost-effective approach. In contrast, the addition of breast MRI to mammographic surveillance produced discordant results. Although MRI resulted in increased quality-adjusted life years, its high ongoing costs lead to several studies finding the use of MRI was not cost-effective compared to either no surveillance or mammography alone.
Analyses of cancer risk management for Australian BRCA1/2 mutation carriers are sparse. Direct comparisons of study outcomes are problematic due to differences in: (1) the defined study population, (2) choice of comparator intervention, (3) timing of interventions, and (4) health-care systems. Although a reasonable proportion of studies modelled the effect of higher uptake of risk management by patients, there is limited consideration of how health-care service delivery could be optimised to achieve this.