Cost-effectiveness analysis (CEA) of ovarian cancer preventive strategies for women with BRCA1/2 pathogenic variants: the role of surveillance.

BACKGROUND: The management of cancer risk for BRCA pathogenic variants (PV) carriers varies depending on countries, with different strategies. However, some strategies lack of cost-effectiveness evidence. This study fills this gap assessing the cost-effectiveness of a combined ovarian cancer (OC) surveillance and prevention strategy in BRCA1/2 PV carriers. METHODS: The developed Markov decision model simulated the progression of breast cancer and OC in BRCA1/2 PV carriers separately. The model estimated benefits and costs associated with three OC surveillance strategies: Surveillance-Surgery (SS), annual surveillance until salpingo-oophorectomy (SO) and radical mastectomy (RM) at appropriate age; Only-Surgery (OS), without surveillance, and No preventive Intervention (NI). Extensive literature review informed the model. The analysis adopted the Italian NHS perspective and a lifetime horizon, with direct healthcare costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio as outcome measures. Base-case, deterministic and probabilistic sensitivity analyses were performed. FINDINGS: In BRCA1 PV carriers, SS yielded lifetime cost savings of €8 382 and €2 008 compared to NI and OS, respectively, while also gaining 2.65 and 0.45 QALYs per patient. Similar trends were observed for BRCA2 PV carriers. Sensitivity analyses confirmed SS as the dominant strategy across all scenarios, with a > 80% probability of being most cost-effective at a willingness-to-pay threshold of €20 000 per QALY gained. INTERPRETATION: Combined OC surveillance and prevention strategy for BRCA1/2 PV carriers at appropriate age represents a highly cost-effective approach compared to surgical prophylaxis alone or no intervention. Periodical counselling in a multidisciplinary team affects high surgical acceptance rates, that are crucial for maximizing the effectiveness of such programs.