Cost-effectiveness of screening with contrast enhanced magnetic resonance imaging vs X-ray mammography of women at a high familial risk of breast cancer

Abstract

Contrast enhanced magnetic resonance imaging (CE MRI) is the most sensitive tool for screening women who are at high familial risk of breast cancer. Our aim in this study was to assess the cost-effectiveness of X-ray mammography (XRM), CE MRI or both strategies combined. In total, 649 women were enrolled in the MARIBS study and screened with both CE MRI and mammography resulting in 1881 screens and 1-7 individual annual screening events. Women aged 35-49 years at high risk of breast cancer, either because they have a strong family history of breast cancer or are tested carriers of a BRCA1, BRCA2 or TP53 mutation or are at a 50% risk of having inherited such a mutation, were recruited from 22 centres and offered annual MRI and XRM for between 2 and 7 years. Information on the number and type of further investigations was collected and specifically calculated unit costs were used to calculate the incremental cost per cancer detected. The numbers of cancer detected was 13 for mammography, 27 for CE MRI and 33 for mammography and CE MRI combined. In the subgroup of BRCA1 (BRCA2) mutation carriers or of women having a first degree relative with a mutation in BRCA1 (BRCA2) corresponding numbers were 3 (6), 12 (7) and 12 (11), respectively. For all women, the incremental cost per cancer detected with CE MRI and mammography combined was pound28 284 compared to mammography. When only BRCA1 or the BRCA2 groups were considered, this cost would be reduced to pound11 731 (CE MRI vs mammography) and pound15 302 (CE MRI and mammography vs mammography). Results were most sensitive to the unit cost estimate for a CE MRI screening test. Contrast-enhanced MRI might be a cost-effective screening modality for women at high risk, particularly for the BRCA1 and BRCA2 subgroups. Further work is needed to assess the impact of screening on mortality and health-related quality of life.

Figure 1

Cost-effectiveness acceptability curve (all women). Curve shows the probability that a screening modality is cost-effective for a range of decision makers' maximum willingness to pay per cancer detected.

Figure 2

Cost-effectiveness acceptability curve for women with mutation in BRCA1 or with a first degree relative with mutation in BRCA1. Curve shows the probability that a screening modality is cost-effective for a range of decision makers' maximum willingness to pay per cancer detected.

Figure 3

Cost-effectiveness acceptability curve for women with mutation in BRCA2 or with a first degree relative with mutation in BRCA2. Curve shows the probability that a screening modality is cost-effective for a range of decision makers' maximum willingness to pay per cancer detected.

Figure 4

Sensitivity analyses: additional costs per cancer detected depending on the unit costs of screening CE MRI and cost associated with further investigations. ICER=incremental cost-effectiveness ratio (additional cost per additional cancer detected), lines represent different costs associated with further investigations.