Prevention with tamoxifen or other hormones versus prophylactic surgery in BRCA/2-positive women

A decision analysis

Victor R. Grann, Judith S. Jacobson, William Whang, Dawn Hershman, Daniel F. Heitjan, Karen H. Amman, Alfred I. Neugut

Research output: Contribution to journalArticle

55 Citations (Scopus)

Abstract

PURPOSE: Recent randomized controlled trials have shown that tamoxifen and raloxifene may prevent invasive breast cancer. This decision analysis study compares the outcomes of chemoprevention with tamoxifen, raloxifene, or oral contraceptives with the outcomes of prophylactic surgery among women with high-risk BRCA1/2 mutations. PATIENTS AND METHODS: We used a simulated cohort of 30-year-old women who tested positive for BRCA1/2 mutations and constructed a Markov model with Monte Carlo simulations, incorporating cumulative breast and ovarian cancer incidence rates from the literature and survival figures from SEER data. We assumed that prophylactic surgery reduces ovarian cancer risk by 45% and breast cancer risk by 90%, that tamoxifen reduces invasive breast cancer risk by 49%, and that raloxifene has similar efficacy and safety in premenopausal and postmenopausal women. We used data obtained from high-risk women by a time trade-off questionnaire to calculate quality-adjusted life-years. We based our cost estimates for hospital and ambulatory care on Health Care Financing Administration payments, the SEER-HCFA database, and the Pharmacy Fundamental Reference. RESULTS: In our model, a 30-year-old BRCA1/2+ woman could prolong survival by 0.9 years (95% probability interval, 0.4-1.2 years) by having bilateral oophorectomy, 3.4 years (2.7-3.7 years) by having bilateral mastectomy, and 4.3 years (3.6-4.6 years) by having both procedures instead of surveillance alone. Chemoprevention with tamoxifen and raloxifene increased survival by 1.6 years (1.0-2.1 years) and 2.2 years (1.3-2.8 years), respectively. Chemoprevention yielded more quality-adjusted life-years than did prophylactic surgery, even when treatment was delayed to age 40 or 50 years. All these procedures were cost-effective or cost-saving compared with surveillance alone. DISCUSSION: Our model suggests that although surgery may yield more substantial survival and cost benefits, quality of life issues may make chemoprevention a more attractive option for young women at high genetic risk.

Original languageEnglish (US)
Pages (from-to)13-20
Number of pages8
JournalCancer Journal
Volume6
Issue number1
StatePublished - Dec 1 2000

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Decision Support Techniques
Tamoxifen
Chemoprevention
Hormones
Breast Neoplasms
Centers for Medicare and Medicaid Services (U.S.)
Quality-Adjusted Life Years
Ovarian Neoplasms
Survival
Costs and Cost Analysis
Mutation
Hospital Costs
Mastectomy
Ovariectomy
Ambulatory Care
Oral Contraceptives
Cost-Benefit Analysis
Survival Rate
Randomized Controlled Trials
Quality of Life

Keywords

  • BRCA1
  • BRCA2
  • Breast cancer
  • Chemoprevention
  • Cost-effectiveness
  • Decision analysis
  • Genetics
  • Ovarian cancer
  • Raloxifene
  • Tamoxifen

ASJC Scopus subject areas

  • Oncology
  • Cancer Research

Cite this

Grann, V. R., Jacobson, J. S., Whang, W., Hershman, D., Heitjan, D. F., Amman, K. H., & Neugut, A. I. (2000). Prevention with tamoxifen or other hormones versus prophylactic surgery in BRCA/2-positive women: A decision analysis. Cancer Journal, 6(1), 13-20.

Prevention with tamoxifen or other hormones versus prophylactic surgery in BRCA/2-positive women : A decision analysis. / Grann, Victor R.; Jacobson, Judith S.; Whang, William; Hershman, Dawn; Heitjan, Daniel F.; Amman, Karen H.; Neugut, Alfred I.

In: Cancer Journal, Vol. 6, No. 1, 01.12.2000, p. 13-20.

Research output: Contribution to journalArticle

Grann, VR, Jacobson, JS, Whang, W, Hershman, D, Heitjan, DF, Amman, KH & Neugut, AI 2000, 'Prevention with tamoxifen or other hormones versus prophylactic surgery in BRCA/2-positive women: A decision analysis', Cancer Journal, vol. 6, no. 1, pp. 13-20.
Grann, Victor R. ; Jacobson, Judith S. ; Whang, William ; Hershman, Dawn ; Heitjan, Daniel F. ; Amman, Karen H. ; Neugut, Alfred I. / Prevention with tamoxifen or other hormones versus prophylactic surgery in BRCA/2-positive women : A decision analysis. In: Cancer Journal. 2000 ; Vol. 6, No. 1. pp. 13-20.
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AU - Whang, William

AU - Hershman, Dawn

AU - Heitjan, Daniel F.

AU - Amman, Karen H.

AU - Neugut, Alfred I.

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N2 - PURPOSE: Recent randomized controlled trials have shown that tamoxifen and raloxifene may prevent invasive breast cancer. This decision analysis study compares the outcomes of chemoprevention with tamoxifen, raloxifene, or oral contraceptives with the outcomes of prophylactic surgery among women with high-risk BRCA1/2 mutations. PATIENTS AND METHODS: We used a simulated cohort of 30-year-old women who tested positive for BRCA1/2 mutations and constructed a Markov model with Monte Carlo simulations, incorporating cumulative breast and ovarian cancer incidence rates from the literature and survival figures from SEER data. We assumed that prophylactic surgery reduces ovarian cancer risk by 45% and breast cancer risk by 90%, that tamoxifen reduces invasive breast cancer risk by 49%, and that raloxifene has similar efficacy and safety in premenopausal and postmenopausal women. We used data obtained from high-risk women by a time trade-off questionnaire to calculate quality-adjusted life-years. We based our cost estimates for hospital and ambulatory care on Health Care Financing Administration payments, the SEER-HCFA database, and the Pharmacy Fundamental Reference. RESULTS: In our model, a 30-year-old BRCA1/2+ woman could prolong survival by 0.9 years (95% probability interval, 0.4-1.2 years) by having bilateral oophorectomy, 3.4 years (2.7-3.7 years) by having bilateral mastectomy, and 4.3 years (3.6-4.6 years) by having both procedures instead of surveillance alone. Chemoprevention with tamoxifen and raloxifene increased survival by 1.6 years (1.0-2.1 years) and 2.2 years (1.3-2.8 years), respectively. Chemoprevention yielded more quality-adjusted life-years than did prophylactic surgery, even when treatment was delayed to age 40 or 50 years. All these procedures were cost-effective or cost-saving compared with surveillance alone. DISCUSSION: Our model suggests that although surgery may yield more substantial survival and cost benefits, quality of life issues may make chemoprevention a more attractive option for young women at high genetic risk.

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