Expanding the criteria BRCA test in young triple negative BC

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Expanding the criteria BRCA test in young triple negative BC

Postby yowyow » Wed Sep 15, 2010 5:59 pm

FINALLY !

Expanding the Criteria for BRCA Mutation Testing in Breast Cancer Survivors
J Clin Oncol. 2010 Aug 23;[Epub Ahead of Print], JS Kwon, AM Gutierrez-Barrera, D Young, CC Sun, MS Daniels, KH Lu, B Arun
Women with triple-negative breast cancer who are younger than 50 years of age would benefit from BRCA-mutation testing.

Supplementary editorial provided by OncologySTAT

TAKE-HOME MESSAGE
Women with triple-negative breast cancer who are younger than 50 years of age would benefit from BRCA-mutation testing.

STUDY IN CONTEXT
Of the 25% of women in the United States diagnosed with breast cancer before 50 years of age, almost 10% will have the BRCA mutation. However, the majority of these women (80%) will not exhibit the characteristics typically thought of in BRCA mutation carriers, eg, Ashkenazi Jewish ancestry or a personal or family history of breast or ovarian cancer. Current USPSTF, NCCN, and ACOG guidelines do not recommend BRCA testing for patients younger than 50 years of age unless there is a personal and a family history of breast or ovarian cancer. Kwon et al used mathematical models to identify subgroups of women with breast cancer who would benefit from BRCA testing.

Six different scenarios for BRCA testing were defined in women with breast cancer who were younger than age 50: (1) no testing (reference group), (2) testing in woman with medullary-only breast cancer, (3) testing in women with any breast cancer who are younger than age 40, (4) testing in women with triple-negative breast cancer who are younger than age 40, (5) testing in women with triple-negative breast cancer who are younger than age 50, (6) testing in all women with breast cancer who are younger than age 50. No other factor, including ethnicity and family history, was used as a criterion for BRCA testing.

Breast-conserving treatment was the assumed treatment (hence a risk of ipsilateral and contralateral cancer recurrence). The proportion of premenopausal patients was assumed as 50% in this mathematical model; also assumed was 60% compliance with prophylactic bilateral mastectomy and bilateral salpingo-oopherectomy (BSO) within 5 years for patients testing positive for BRCA. The mathematical models specified that BRCA mutation carriers would have a 90% reduction in the risk of breast cancer if they underwent prophylactic mastectomy and a 90% reduction in ovarian cancer with prophylactic BSO.

An incremental cost-effectiveness ratio (ICER) was calculated based on these mathematical models for each defined BRCA testing group. ICER was calculated as the average lifetime cost (US dollars in 2009) as a proportion of the average life expectance gain in years. A testing criterion was considered cost-effective if the ICER was below $50,000 per year of life gained.

Not surprisingly, the testing criterion with the greatest cost and also the greatest life expectancy was the most inclusive testing criterion, ie, all women younger than 50 years with breast cancer being tested for BRCA mutation. However, the ICER was considered unfavorable, at $59,503 per year of life and $112,908 quality-adjusted life-year gained. The testing criterion with the greatest potential benefit and the most favorable ICER ($1,160) was the one for triple-negative breast cancer patients being tested at younger than 50 years of age. Modifying the estimates of the number of BRCA patients who would undergo prophylactic surgical therapy from 60% (realistic) to 100% (ideal) showed that testing women with triple-negative breast cancer still had the most favorable ICER. Based on these mathematical models, testing women with triple-negative breast cancer who were younger than 50 years of age for BRCA mutations would reduce subsequent breast and ovarian cancer risks by 23% and 41%, respectively.

This mathematical analysis clearly showed that, for women with triple-negative breast cancer who were younger than 50 years of age, the estimated costs and net health benefits favor routine BRCA screening, regardless of family history or ethnicity.
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