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Original Investigation
July 30, 2020

Cost-effectiveness of Breast Cancer Screening With Magnetic Resonance Imaging for Women at Familial Risk

Author Affiliations
  • 1Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
  • 2Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
  • 3Department of Surgery, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
  • 4Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
  • 5Department of Radiology and Nuclear Medicine, Radboud University Hospital, Nijmegen, the Netherlands
  • 6Department of Radiology and Nuclear Medicine, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
  • 7Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
  • 8Department of Genetics, Groningen University, University Medical Centre Groningen, Groningen, the Netherlands
  • 9Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
  • 10Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
  • 11Department of Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands
  • 12Department of Medical Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
  • 13Department of Genetics, University Medical Centre Utrecht, Utrecht, the Netherlands
  • 14Department of Pathology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
  • 15Department of Surgery, Amphia Ziekenhuis, Breda, the Netherlands
  • 16Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
JAMA Oncol. Published online July 30, 2020. doi:10.1001/jamaoncol.2020.2922
Key Points

Question  Is magnetic resonance imaging screening cost-effective for women with a 20% or more familial risk of breast cancer without a known BRCA1/2 or TP53 variant, and what is the optimal screening strategy?

Findings  This economic evaluation found that magnetic resonance imaging every 18 months between ages of 35 and 60 years followed by the national screening program until age 75 years was cost-effective and considered optimal within the National Institute for Health and Care Excellence threshold for all densities. Higher thresholds would favor annual magnetic resonance imaging screening.

Meaning  These outcomes support a change of current screening guidelines for this specific risk group and support magnetic resonance imaging screening; the decision on which strategy to choose will also depend on the willingness to pay.

Abstract

Importance  For women with a 20% or more familial risk of breast cancer without a known BRCA1/2 (BRCA1, OMIM 113705; and BRCA2, OMIM 114480) or TP53 (OMIM 151623) variant, screening guidelines vary substantially, and cost-effectiveness analyses are scarce.

Objective  To assess the cost-effectiveness of magnetic resonance imaging (MRI) screening strategies for women with a 20% or more familial risk for breast cancer without a known BRCA1/2 or TP53 variant.

Design, Setting, and Participants  In this economic evaluation, conducted from February 1, 2019, to May 25, 2020, microsimulation modeling was used to estimate costs and effectiveness on a lifetime horizon from age 25 years until death of MRI screening among a cohort of 10 million Dutch women with a 20% or more familial risk for breast cancer without a known BRCA1/2 or TP53 variant. A Dutch screening setting was modeled. Most data were obtained from the randomized Familial MRI Screening (FaMRIsc) trial, which included Dutch women aged 30 to 55 years. A health care payer perspective was applied.

Interventions  Several screening protocols with varying ages and intervals including those of the randomized FaMRIsc trial, consisting of the mammography (Mx) protocol (annual mammography and clinical breast examination) and the MRI protocol (annual MRI and clinical breast examination plus biennial mammography).

Main Outcomes and Measures  Costs, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated and discounted by 3%. A threshold of €22 000 (US $24 795.87) per QALY was applied.

Results  This economic evaluation modeling study estimated that, on a lifetime horizon per 1000 women with the Mx protocol of the FaMRIsc trial, 346 breast cancers would be detected, and 49 women were estimated to die from breast cancer, resulting in 22 885 QALYs and total costs of €7 084 767 (US $7 985 134.61). The MRI protocol resulted in 79 additional QALYs and additional €2 657 266 (US $2 994 964.65). Magnetic resonance imaging performed only every 18 months between the ages of 35 and 60 years followed by the national screening program was considered optimal, with an ICER of €21 380 (US $24 097.08) compared with the previous nondominated strategy in the ranking, when applying the National Institute for Health and Care Excellence threshold. Annual screening alternating MRI and mammography between the ages of 35 and 60 years, followed by the national screening program, gave similar outcomes. Higher thresholds would favor annual MRI screening. The ICER was most sensitive to the unit cost of MRI and the utility value for ductal carcinoma in situ and localized breast cancer.

Conclusions and Relevance  This study suggests that MRI screening every 18 months between the ages of 35 and 60 years for women with a family history of breast cancer is cost-effective within the National Institute for Health and Care Excellence threshold for all densities. Higher thresholds would favor annual MRI screening. These outcomes support a change of current screening guidelines for this specific risk group and support MRI screening.

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