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66 Should we offer multi-gene testing to all patients with breast cancer: a cost-effectiveness analysis
  1. L Sun1,2,
  2. A Brentnall3,
  3. S Patel2,
  4. D Buist SM4,
  5. E Bowles JA4,
  6. DG Evans R5,
  7. D Eccles6,
  8. J Hopper7,
  9. S Li7,
  10. S Duffy3,
  11. J Cuzick3,
  12. I dos-Santos-Silva8,
  13. Z Sadique1,
  14. L Yang9,
  15. R Legood1 and
  16. R Manchanda2,10,11
  1. 1London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, UK
  2. 2Barts Cancer Institute- Queen Mary University of London, Centre for Experimental Cancer Medicine, London, UK
  3. 3Wolfson Institute of Preventive Medicine- Queen Mary University of London, Centre for Cancer Prevention, London, UK
  4. 4Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington Health Research Institute, Seattle, USA
  5. 5The University of Manchester, Genomic Medicine- Manchester Academic Health Science Centre MAHSC- Manchester Universities Foundation Trust- St. Mary’s Hospital, London, UK
  6. 6University of Southampton, Cancer Sciences Academic Unit- Faculty of Medicine and Cancer Sciences, Southampton, UK
  7. 7University of Melbourne, Centre for Epidemiology and Biostatistics- Melbourne School of Population and Global Health- Faculty of Medicine- Dentistry and Health Sciences, Melbourne, Australia
  8. 8London School of Hygiene and Tropical Medicine, Department of Non-communicable Disease Epidemiology, London, UK
  9. 9Peking University, School of Public Health, Beijing, China
  10. 10Barts Health NHS Trust- Royal London Hospital, Department of Gynaecological Oncology, London, UK
  11. 11University College London, MRC Clinical Trials Unit at UCL- Institute of Clinical Trials and Methodology- Faculty of Population Health Sciences, London, UK


Objectives To estimate incremental lifetime-effects, costs, cost-effectiveness and population impact of multigene-testing all BC patients compared to current practice of family-history/clinical-criteria based genetic (BRCA)-testing.

Methods Cost-effectiveness microsimulation modelling study comparing lifetime costs-&-effects of BRCA1/BRCA2/PALB2(multigene) testing all unselected BC-cases (Strategy-A) with family-history/clinical-criteria based BRCA1/BRCA2-testing (Strategy-B) in both UK and US populations.Data obtained from 11,836 population-based BC-patients (regardless of family-history) recruited to four large research studies in the UK (Predicting-Risk-of-Breast-Cancer-at-Screening (PROCAS: 1389 out of 57,000 women) & Prospective-Outcomes-in-Sporadic-versus-Hereditary-breast-cancer (POSH: 2885) studies); US (Kaiser-Permanente Washington Breast-Cancer-Surveillance-Consortium (BCSC) registry: 5892 out of 132,139 women) and Australia (Population-based BC-cases of the Australian-Breast-Cancer-Family-Study (ABCFS: 1670 women)). The main outcome measure was the incremental cost per quality-adjusted life-year (QALY) gained with a 3.5% annual discount. Parameter uncertainty was explored using one-way and probabilistic sensitivity analyses.

Results Compared with current clinical-criteria/family-history-based BRCA-testing, (BRCA1/BRCA2/PALB2) multigene-testing for all BC-patients would cost £10,470/QALY (UK) or $58,702/QALY (US) gained, well below UK/NICE and US cost-effectiveness thresholds of £30,000/QALY & $100,000/QALY. Probabilistic sensitivity-analysis shows unselected multigene-testing remains cost-effective for 98% UK/77% US health-system simulations. One year’s unselected panel-genetic testing can prevent 1,776 BC/OC-cases and 557 deaths in the UK; and 8,258 BC/OC-cases and 2,143 deaths in the US. Correspondingly, 7 UK/32 US excess heart-disease deaths occur annually.

Conclusions Unselected multigene-testing for all BC patients is extremely cost-effective compared with family-history/clinical-criteria testing for UK and US health-systems. It prevents thousands more BC/OC cases and deaths. We recommend changing current policy to expand genetic-testing to all BC patients.

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