Grann V R, Panageas K S, Whang W, Antman K H, Neugut A I
Herbert Irving Comprehensive Cancer Center of Columbia University, School of Public Health, New York, NY 10032, USA.
J Clin Oncol. 1998 Mar;16(3):979-85. doi: 10.1200/JCO.1998.16.3.979.
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. Many question whether they should have prophylactic surgical procedures, ie, bilateral mastectomy and/or oophorectomy.
A Markov model was developed to determine the survival, quality of life, and cost-effectiveness of prophylactic surgical procedures. The probabilities of developing breast and ovarian cancer were based on literature review among women with the BRCA1 or BRCA2 gene and mortality rates were determined from Surveillance, Epidemiology, and End Results (SEER) data for 1973 to 1992. The costs for hospital and ambulatory care were estimated from Health Care Financing Administration (HCFA) payments in 1995, supplemented by managed care and fee-for-service data. Utility measures for quality-adjusted life-years (QALYs) were explicitly determined using the time-trade off method. Estimated risks for breast and ovarian cancer after prophylactic surgeries were obtained from the literature.
For a 30-year-old woman, according to her cancer risks, prophylactic oophorectomy improved survival by 0.4 to 2.6 years; mastectomy, 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.
Among women who test positive for a BRCA1 or BRCA2 gene mutation, prophylactic surgery at a young age substantially improves survival, but unless genetic risk of cancer is high, provides no benefit for quality of life. Prophylactic surgery is cost-effective for years of life saved compared with other medical interventions that are deemed cost-effective.
携带BRCA1或BRCA2突变基因检测呈阳性的年轻阿什肯纳兹犹太女性或来自高危家庭的女性，到70岁时患乳腺癌或卵巢癌的风险显著。许多人质疑她们是否应该接受预防性手术，即双侧乳房切除术和/或卵巢切除术。
建立马尔可夫模型以确定预防性手术的生存率、生活质量和成本效益。患乳腺癌和卵巢癌的概率基于对携带BRCA1或BRCA2基因女性的文献综述，死亡率根据1973年至1992年的监测、流行病学和最终结果（SEER）数据确定。医院和门诊护理费用根据1995年医疗保健财务管理局（HCFA）的支付情况估算，并辅以管理式医疗和按服务收费数据。使用时间权衡法明确确定质量调整生命年（QALY）的效用指标。预防性手术后乳腺癌和卵巢癌的估计风险来自文献。
对于一名30岁的女性，根据其癌症风险，预防性卵巢切除术使生存期延长0.4至2.6年；乳房切除术使生存期延长2.8至3.4年；乳房切除术和卵巢切除术使生存期比监测延长3.3至6.0年。在高危模型中，卵巢切除术节省的QALY为0.5，联合手术节省的QALY为1.9。与监测相比，预防性手术在挽救生命年数方面具有成本效益，但在QALY方面则不然。
在BRCA1或BRCA2基因突变检测呈阳性的女性中，年轻时进行预防性手术可显著提高生存率，但除非癌症遗传风险很高，否则对生活质量没有益处。与其他被认为具有成本效益的医疗干预措施相比，预防性手术在挽救生命年数方面具有成本效益。
