Department of Breast Surgical Oncology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan.
CRECON Medical Assessment Inc., The Pharmaceutical Society of Japan, Nagai Memorial, 12-15 Shibuya 2-chome, Shibuya-ku, Tokyo, 150-0002, Japan.
Breast Cancer. 2018 Mar;25(2):141-150. doi: 10.1007/s12282-017-0803-y. Epub 2017 Oct 10.
Cost-effectiveness analysis is an important aspect of healthcare, including in Japan, where preventive measures for BRCA1/2 mutation carriers are not covered by health insurance.
We developed Markov models in a simulated cohort of women aged 35-70 years, and compared outcomes of surveillance with risk-reducing mastectomy (RRM) at age 35, risk-reducing salpingo-oophorectomy (RRSO) at age 45, and both (RRM&RRSO). We used breast and ovarian cancer incidences and adverse event rates from the previous studies, adjuvant chemotherapy, and hormonal therapy rates from the Hereditary Breast and Ovarian Cancer Registration 2015 in Japan, mortality rates from the National Cancer Center Hospital, Japan Society of Clinical Oncology, and Ministry of Health, Labour and Welfare, and direct costs from St. Luke's International Hospital and Keio University Hospital. We used previously published preference ratings of women without known high risk to adjust survival for quality of life. The discount rate was 2%.
Compared with surveillance, RRSO and RRM&RRSO were dominant (both cost-saving and more effective), and RRM was cost-effective in BRCA1 mutation carriers, while RRM and RRM&RRSO were dominant and RRSO was cost-effective in BRCA2. Among the four strategies including surveillance, RRM&RRSO and RRM were the most cost-effective in BRCA1 and BRCA2 mutation carriers, respectively.
With quality adjustment, RRM, RRSO, and RRM&RRSO were all cost-effective preventive strategies in BRCA1/2 mutation carriers, with RRM&RRSO being the most cost-effective in BRCA1 and RRM in BRCA2. This result supports the inclusion of insurance coverage for BRCA mutation carriers in Japan.
成本效益分析是医疗保健的一个重要方面，包括在日本，BRCA1/2 突变携带者的预防措施不受医疗保险覆盖。
我们在一个模拟的 35-70 岁女性队列中开发了马尔可夫模型，并比较了 35 岁时进行监测、降低风险的乳房切除术（RRM）、45 岁时进行降低风险的输卵管卵巢切除术（RRSO）以及两者（RRM&RRSO）的结果。我们使用了之前研究中的乳腺癌和卵巢癌发病率和不良事件发生率、辅助化疗和激素治疗率来自日本遗传性乳腺癌和卵巢癌登记 2015 年，来自日本国立癌症中心医院、日本临床肿瘤学会和厚生劳动省的死亡率，以及圣卢克国际医院和庆应义塾大学医院的直接费用。我们使用了之前发表的无已知高风险的女性偏好评分来调整生存质量。折扣率为 2%。
与监测相比，RRSO 和 RRM&RRSO 具有优势（既节省成本又更有效），BRCA1 突变携带者的 RRM 具有成本效益，而 BRCA2 突变携带者的 RRM 和 RRM&RRSO 具有优势，RRSO 具有成本效益。在包括监测在内的四种策略中，RRM&RRSO 和 RRM 在 BRCA1 和 BRCA2 突变携带者中分别是最具成本效益的策略。
经过质量调整，RRM、RRSO 和 RRM&RRSO 都是 BRCA1/2 突变携带者的有效预防策略，RRM&RRSO 在 BRCA1 中最具成本效益，而 RRM 在 BRCA2 中最具成本效益。这一结果支持日本为 BRCA 突变携带者纳入保险覆盖范围。
