Breast Cancer Screening by MRI cost-effective for females with genetic risk: JAMA

In women with a family history of breast cancer, regular magnetic resonance imaging (MRI) screening for every 18 months between the ages 35 and 60yrs is cost effective, finds a study. The study was published in the journal, 'JAMA Oncology' 2020.

There are various screening guidelines for women with a 20% or more familial risk of breast cancer without a known BRCA1/2 or TP53 variant and these guidelines vary substantially. The cost-effectiveness analyses are also very scarce. The economic evaluation was conducted from February 1, 2019, to May 25, 2020. A Dutch screening setting was modeled and a microsimulation modelling was used to estimate costs and effectiveness on a lifetime horizon from age 25 years until death of the MRI screening among a cohort of 10 million Dutch women with a 20% or more familial risk for breast cancer without a known BRCA1/2 or TP53 variant. Data was obtained from the randomized Familial MRI Screening (FaMRIsc) trial, which included Dutch women aged 30 to 55 years. A health care payer perspective was applied.

Several screening protocols including the randomized FaMRIsc trial, which consisted of the mammography and the MRI protocol were used. Main outcome of measurement were costs, life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) which were calculated and discounted by 3%. A threshold of €22 000 (US $24 795.87) per QALY was applied.

The key findings of the study are:

• This economic evaluation modeling study estimated that, on a lifetime horizon per 1000 women with the Mx protocol of the FaMRIsc trial, 346 breast cancers would be detected, and 49 women were estimated to die from breast cancer, resulting in 22 885 QALYs and total costs of €7 084 767 (US $7 985 134.61).
• The MRI protocol resulted in 79 additional QALYs and additional €2 657 266 (US $2 994 964.65).
• Magnetic resonance imaging performed only every 18 months between the ages of 35 and 60 years followed by the national screening program was considered optimal, with an ICER of €21 380 (US $24 097.08) compared with the previous nondominated strategy in the ranking, when applying the National Institute for Health and Care Excellence threshold.
  
• Annual screening alternating magnetic resonance imaging  and mammography between the ages of 35 and 60 years, followed by the national screening program, gave similar outcomes.
  
• Higher thresholds would favor annual magnetic resonance imaging  screening.
  
• The ICER was most sensitive to the unit cost of magnetic resonance imaging  (MRI) and the utility value for ductal carcinoma in situ and localized breast cancer.
  

Thus, the researchers concluded that MRI screening every 18 months between the ages of 35 and 60 years for women with a family history of breast cancer is cost-effective within the National Institute for Health and Care Excellence threshold for all densities. They further added that Higher thresholds would favor annual magnetic resonance imaging (MRI) screening and also that These outcomes should support a change of current screening guidelines for this specific risk group and support MRI.  

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JAMA Oncol. Published online July 30, 2020.