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Evaluation of Breast Cancer Risk Assessment Techniques: A Cost-effectiveness Analysis

¹ Institute for Technology Assessment at Massachusetts General Hospital, Department of Radiology, Harvard Medical School, Boston, Massachusetts; and ² Carol Franc Breast Care Center, Department of Surgery, University of California San Francisco Medical Center, San Francisco, California

Requests for reprints: Elissa M. Ozanne, Institute for Technology Assessment at Massachusetts General Hospital, Department of Radiology, Harvard Medical School, 101 Merrimac Street, 10th Floor, Boston, MA 02114-4724. Phone: 617-724-4445; Fax: 617-726-9414. E-mail: elissa{at}mgh-ita.org

Objective: Assess the effectiveness and cost-effectiveness of using biomarkers and risk assessment tools to stratify women for breast cancer preventive interventions.

Methods: A Markov model was developed to compare risk management strategies for high-risk women considering chemoprevention. Annual screening is compared to the use of chemoprevention for all women and the use of risk assessment technologies to stratify patients for chemoprevention. The biomarker atypia was used to stratify women by risk. Random fine-needle aspiration (rFNA) and ductal lavage (DL) were evaluated and compared as the risk assessment tools used to discover atypia. Sensitivity analyses explore assumptions regarding the prognostic and predictive characteristics of atypia, both the relative breast cancer risk and benefit from chemoprevention women with atypia incur.

Results: Risk assessment strategies using rFNA or DL in combination with chemoprevention are found to be cost-effective (<$50,000 per life year saved) in high-risk groups under most scenarios. Both strategies were more effective and less costly in younger cohorts. Effectiveness of the risk assessment strategies increased when higher risk and increased benefit from chemoprevention were associated with atypia. Within the scenarios tested, rFNA is less costly than DL.

Conclusion: rFNA and DL appear to be cost-effective in high-risk women, assuming women with detected atypia choose tamoxifen. The tools are largely effective for women who are not motivated to take tamoxifen but would be if atypia were found. As biomarker risk assessment tools better predict the risk of breast cancer and or benefit of interventions, their cost-effectiveness increases.

Key Words: Tamoxifen • Fine-Needle Aspiration • Ductal Lavage • Breast Cancer Prevention • Cost-effectiveness

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