The cost-utility of targeted germline BRCA testing in localized prostate cancer followed by cascade testing first-degree relatives with pathogenic variants

Abstract

Purpose

Genetic testing is recommended in localized prostate cancer (PCa) with elevated risk and in metastatic PCa. The economics of genetic testing in metastatic PCa has been evaluated but not assessed in localized PCa. We examined the cost utility of germline BRCA testing in localized PCa with high risk of pathogenic variants.

Methods

Cost-utility analysis of germline BRCA testing in localized PCa with (1) high/very high-risk classification, (2) family history of PCa, and (3) Ashkenazi-Jewish ancestry. Analyses were performed from an Australian payer perspective using semi-Markov models over lifetime; quality-adjusted life years (QALYs) were the health outcomes. Decision uncertainty was characterized using 1-way and probabilistic sensitivity analyses.

Results

The incremental cost-effectiveness ratio of BRCA testing compared with no testing was AU$591,408/QALY in patients with high/very high risk, AU$3.9 million/QALY with family history of PCa, and AU$650,098/QALY in Ashkenazi-Jews. Adding cascade testing of first-degree relatives (FDRs) resulted in incremental cost-effectiveness ratios of AU$18,872/QALY, AU$47,294/QALY, and AU$14,637/QALY in the aforementioned groups. At a willingness-to-pay of AU$75,000/QALY, BRCA testing was not likely to be cost-effective in PCa patients; however, it was cost-effective after cascade testing FDRs.

Conclusion

Germline BRCA testing may not be cost-effective when limited to patients with localized PCa but demonstrates value for money when extended to FDRs.