Cost-Effectiveness of Prophylactic Mastectomy and Autologous Flap Reconstruction in BRCA1/2+ Patients: A Markov Chain Monte Carlo Simulation Analysis.

Abstract

Introduction: Patients diagnosed with Breast Cancer gene (BRCA) 1 or 2 face a critical choice between prophylactic mastectomy versus serial surveillance screening. This study aims to evaluate the cost-effectiveness of prophylactic mastectomy with autologous reconstruction compared to surveillance strategies for this patient population.

Methods: Markov Chain Monte Carlo (MCMC) simulations comprising 100,000 patients were used. All models assumed a baseline of women aged 25 with BRCA1 or BRCA2 mutations. In the standard of care model, patients underwent annual screening (MRI+Mammography) until 75. Positive screenings led to mastectomy followed by two-stage breast reconstruction using tissue expanders-to-implants. This approach was compared to prophylactic mastectomy with autologous flap reconstruction (free-TRAM, gluteal, thigh, or DIEP) at ages 30, 35, or 40. Evaluation parameters included cost, quality of life, and incremental cost-effectiveness ratios (ICER).

Results: All autologous flaps ICERs were below the willingness-to-pay threshold of $50,000, suggesting cost-effectiveness, with DIEP flaps being the lowest. Prophylactic mastectomy with autologous reconstruction was more cost effective for BRCA1 than BRCA2 patients and sensitivity analysis revealed that prophylaxis became cost-effective earliest for DIEP flaps (50-63) and latest for gluteal flaps (58-73).

Conclusion: Prophylactic mastectomy with autologous reconstruction performed at ages 30, 35 or 40, was found to be a cost-effective alternative to breast cancer surveillance and disease treatment in women with BRCA1/2 mutations. DIEP and free TRAM flaps were the most cost-effective techniques and prophylaxis was more cost effective in BRCA1 than BRCA 2 patients.