New UK modelling suggests that offering mastectomies to more women at risk of breast cancer could save thousands of lives.
The analysis, published in JAMA Oncology, finds the surgical technique is a cost-effective way of reducing the likelihood of developing breast cancer compared to breast screening and medication.
As a result, current guidelines on who is offered a mastectomy may need to be revised.
Clinicians currently use personalised risk prediction models that combine genetic and other data to identify those women at a higher risk of developing breast cancer.
Subsequent treatment options – including mammograms, MRI screening, surgery and medication – are then offered, depending on the level of risk.
Risk-reducing mastectomy is recommended for women at high risk. However, in practice, this surgery is only clinically offered to those pathogenic variants known to increase the likelihood of developing the disease (BRCA1/BRCA2/PALB2 PV).
Professor Ranjit Manchanda from Queen Mary University of London, Dr Rosa Legood from the London School of Hygiene and Tropical Medicine, along with colleagues from the University of Manchester and Peking University, developed a new economic evaluation model to accurately predict the level of risk at which RRM becomes more cost-effective.
For their model, researchers followed NICE guidelines to assess whether a treatment is cost-effective.
Their model demonstrated that mastectomy is a cost-effective treatment for women aged 30 or older with a lifetime breast cancer risk of at least 35%.
Offering RRM to women in this cohort could potentially prevent 6,500 of the 58,500 cases of breast cancer diagnosed every year in the UK.
Professor Manchanda, Professor of Gynaecological Oncology at Queen Mary and Consultant Gynaecological Oncologist, said: ‘We for the first time define the risk at which we should offer RRM. Our results could have significant clinical implications, expanding access to mastectomy beyond patients with known genetic susceptibility in high-penetrance genes, such as BRCA1/ BRCA2/ PALB2, who are traditionally offered this treatment. This could potentially prevent 6,500 breast cancer cases annually in UK women. We recommend that more research be carried out to evaluate the acceptability, uptake, and long-term outcomes of RRM among this group.’
Dr Legood, associate professor in health economics at the London School of Hygiene & Tropical Medicine, said: ‘Undergoing RRM is cost-effective for women 30-55 years with a lifetime breast cancer risk of 35% or more. These results can support additional management options for personalised breast cancer risk prediction, enabling more women at increased risk to access prevention.’
The researchers used data from women aged between 30 and 60 with varying lifetime breast cancer risks between 17% and 50%, and who were either undergoing RRM or receiving screening with medical prevention according to currently used predictive models.
NICE considers a treatment cost-effective if it typically provides one additional year of health for no more than £20,000-£30,000 per patient, known as the ‘willingness to pay’ threshold, or WTP. The researchers’ model used a threshold of £30,000 per Quality Adjusted Life Year.
