Cost Effectiveness of Prophylactic Mastectomy and Autologous Flap Reconstruction in BRCA1/2 -Positive Patients.

Background: Patients diagnosed with having the breast cancer gene ( BRCA1 or BRCA2 ) face a critical choice between prophylactic mastectomy and serial surveillance screening. This study aimed to evaluate the cost effectiveness of prophylactic mastectomy with autologous reconstruction compared with surveillance strategies for this patient population.

Methods: Markov chain Monte Carlo simulations comprising 100,000 patients were used. All models assumed a baseline of women aged 25 years with BRCA1 or BRCA2 mutations. In the standard-of-care model, patients underwent annual screening (magnetic resonance imaging plus mammography) until age 75 years. Positive screenings led to mastectomy followed by 2-stage breast reconstruction using tissue expanders and implants. This approach was compared with prophylactic mastectomy with autologous flap reconstruction (free transverse rectus abdominis myocutaneous, gluteal, thigh, or deep inferior epigastric perforator [DIEP] flaps) at ages 30, 35, or 40 years. Evaluation parameters included cost, quality of life, and incremental cost-effectiveness ratios.

Results: The incremental cost-effectiveness ratios of all autologous flaps 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 patients than for BRCA2 patients, and sensitivity analysis revealed that prophylaxis became cost effective earliest for DIEP flaps (ages 50 to 63 years) and latest for gluteal flaps (ages 58 to 73 years).

Conclusions: Prophylactic mastectomy with autologous reconstruction performed at ages 30, 35 or 40 years, was found to be a cost-effective alternative to breast cancer surveillance and disease treatment in women with BRCA1/2 mutations. DIEP and free transverse rectus abdominis myocutaneous flaps were the most cost-effective techniques, and prophylaxis was more cost effective in BRCA1 patients than in BRCA2 patients.