Economic Modelling of Screen-and-Treat Strategies for Brazilian Women at Risk of Hereditary Breast and Ovarian Cancer

Economic evaluation of germline genetic testing for breast cancer in low- and middle-income countries: a systematic review

BACKGROUND

Breast cancer (BC) is the most common cancer affecting women globally. Genetic testing serves as a prevention and treatment strategy for managing BC. This study aims to systematically review economic evaluations and the quality of selected studies involving genetic screening strategies for BC in low and middle-income countries (LMICs).

METHODS

A search was performed to identify related articles that were published up to April 2023 on PubMed, Embase, CINAHL, Web of Science, and the Centre for Reviews and Dissemination. Only English-language LMIC studies were included. Synthesis of studies characteristics, methodological and data input variations, incremental cost-effectiveness ratios (ICERs), and reporting quality (Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist) were performed.

RESULTS

This review found five pertinent studies, mainly focusing on economic evaluations of germline genetic testing in upper-middle-income countries (Upper MICs) like Malaysia, China, and Brazil. Only one study covered multiple countries with varying incomes, including lower-middle-income nations (Lower MICs) like India. The ICERs values in various screening scenarios for early-stage BC, HER2 negative BC patients, and healthy women with clinical or family history criteria were ranging from USD 2214/QALY to USD 36,342/QALY. Multigene testing for all breast cancer patients with cascade testing was at USD 7729/QALY compared to BRCA alone. Most studies adhered to the CHEERS 2022 criteria, signifying high methodological quality.

CONCLUSIONS

Germline testing could be considered as cost-effective compared to no testing in Upper MICs (e.g., Malaysia, China, Brazil) but not in Lower MICs (e.g., India) based on the willingness-to-pay (WTP) threshold set by each respective study. Limitations prevent a definite conclusion about cost-effectiveness across LMICs. More high-quality studies are crucial for informed decision-making and improved healthcare practices in these regions.

Economic evaluations of predictive genetic testing: A scoping review

Predictive genetic testing can provide information about whether or not someone will develop or is likely to develop a specific condition at a later stage in life. Economic evaluation can assess the value of money for such testing. Studies on the economic evaluation of predictive genetic testing have been carried out in a variety of settings, and this research aims to conduct a scoping review of findings from these studies. We searched the PubMed, Web of Science, Embase, and Cochrane databases with combined search terms, from 2019 to 2022. Relevant studies from 2013 to 2019 in a previous systematic review were also included. The study followed the recommended stages for undertaking a scoping review. A total of 53 studies were included, including 33 studies from the previous review and 20 studies from the search of databases. A significant number of studies focused on the US, UK, and Australia (34%, 23%, and 11%). The most frequently included health conditions were cancer and cardiovascular diseases (68% and 19%). Over half of the studies compared predictive genetic testing with no genetic testing, and the majority of them concluded that at least some type of genetic testing was cost-effective compared to no testing (94%). Some studies stated that predictive genetic testing is becoming more cost-effective with the trend of lowering genetic testing costs. Studies on predictive genetic testing covered various health conditions, particularly cancer and cardiovascular diseases. Most studies indicated that predictive genetic testing is cost-effective compared to no testing.

Cost-effectiveness of stereotactic body radiotherapy versus conventional radiotherapy for the treatment of surgically ineligible stage I non-small cell lung cancer in the Brazilian public health system

Background

The Brazilian public health system does not pay for the use of Stereotactic body radiotherapy (SBRT) due to its costs and the absence of cost-effectiveness analysis showing its benefit. The present study aims to evaluate whether the SBRT is a more cost-effective strategy than the conventional fractionated radiotherapy (CFRT) for surgically ineligible stage I non-small cell lung cancer (NSCLC) in the Brazilian public health system.

Methods

Adopting the perspective of the Brazilian Unified Healthcare System (SUS) as the payer, a Markov model with a lifetime horizon was built to delineate the health states for a cohort of 75-years-old men with medically inoperable NSCLC after treatment with SBRT or CFRT. Transition probabilities and health states utilities were adapted from the literature. Costs were based on the public health system reimbursement values and simulated in the private sector.

Findings

The SBRT strategy results in more quality-adjusted life-year (QALYs) and costs with an incremental cost-effectiveness ratio (ICER) of R$ 164.86 (U$ 65.16) per QALY and R$ 105 (U$ 41.50) per life-year gained (LYG). This strategy was cost-effective, considering a willingness-to-pay of R$ 25,000 (U$ 9,881.42) per QALY. The net monetary benefit (NMB) was approximately twice higher. The outcomes were confirmed with 92% of accuracy in the probabilistic sensitivity analysis.

Interpretation

Using a threshold of R$25,000 per QALY, SBRT was more cost-effective than CFRT for NSCLC in a public health system of an upper-middle-income country. SBRT generates higher NMB than CFRT, which could open the opportunity to incorporate new technologies.

Funding

Varian Medical Systems.

Cost-Effectiveness of BRCA 1/2 Genetic Test and Preventive Strategies: Using Real-World Data From an Upper-Middle Income Country

Although BRCA1/2 genetic testing in developed countries is part of the reality for high-risk patients for hereditary breast and ovarian cancer (HBOC), the same is not true for upper-middle-income countries. For that reason, this study aimed to evaluate whether the BRCA1/2 genetic test and preventive strategies for women at high risk for HBOC are cost-effective compared to not performing these strategies in an upper-middle-income country. Adopting a payer perspective, a Markov model with a time horizon of 70 years was built to delineate the health states for a cohort of healthy women aged 30 years that fulfilled the BRCA1/2 testing criteria according to the guidelines. Transition probabilities were calculated based on real-world data of women tested for BRCA1/2 germline mutations in a cancer reference hospital from 2011 to 2020. We analyzed 275 BRCA mutated index cases and 356 BRCA mutation carriers that were first- or second-degree relatives of the patients. Costs were based on the Brazilian public health system reimbursement values. Health state utilities were retrieved from literature. The BRCA1/2 genetic test and preventive strategies result in more quality-adjusted life years (QALYs) and costs with an incremental cost-effectiveness ratio of R$ 11,900.31 (U$ 5,504.31)/QALY. This result can represent a strong argument in favor of implementing genetic testing strategies for high-risk women even in countries with upper-middle income, considering not only the cancer prevention possibilities associated with the genetic testing but also its cost-effectiveness to the health system. These strategies are cost-effective, considering a willingness-to-pay threshold of R$ 25,000 (U$ 11,563.37)/QALY, indicating that the government should consider offering them for women at high risk for HBOC. The results were robust in deterministic and probabilistic sensitivity analyses.

Uptake Rates of Risk-Reducing Surgeries for Women at Increased Risk of Hereditary Breast and Ovarian Cancer Applied to Cost-Effectiveness Analyses: A Scoping Systematic Review

Simple Summary

For women who have tested positive for BRCA mutations, the decision to make use of preventive surgical options, such as risk-reducing mastectomy (RRM) or risk-reducing bilateral salpingo-oophorectomy (RRSO), depends on the women’s personal preferences and the cultural/social context. Among others, the cost-effectiveness of RRM and RRSO can be affected by the uptake rate of these preventive surgical options. Uptake rates of surgery should be given more attention in the conceptualization of health economic modeling studies for RRM and RRSO. Prospective multicenter studies are recommended to reflect regional and national variations in women’s preferences for preventive surgery.

Abstract

The cost-effectiveness of genetic screen-and-treat strategies for women at increased risk for breast and ovarian cancer often depends on the women’s willingness to make use of risk-reducing mastectomy (RRM) or salpingo-oophorectomy (RRSO). To explore the uptake rates of RRM and RRSO applied in health economic modeling studies and the impact of uptake rates on the incremental cost-effectiveness ratios (ICER), we conducted a scoping literature review. In addition, using our own model, we conducted a value of information (VOI) analysis. Among the 19 models included in the review, the uptake rates of RRM ranged from 6% to 47% (RRSO: 10% to 88%). Fifty-seven percent of the models applied retrospective data obtained from registries, hospital records, or questionnaires. According to the models’ deterministic sensitivity analyses, there is a clear trend that a lower uptake rate increased the ICER and vice versa. Our VOI analysis showed high decision uncertainty associated with the uptake rates. In the future, uptake rates should be given more attention in the conceptualization of health economic modeling studies. Prospective studies are recommended to reflect regional and national variations in women’s preferences for preventive surgery.

Data on Utility in Cost-Utility Analyses of Genetic Screen-and-Treat Strategies for Breast and Ovarian Cancer

Simple Summary

The prevention of hereditary breast and ovarian cancer involves genetic counselling and several highly preference-sensitive alternatives (i.e., risk-reducing surgeries). In health economics models, data on health preferences applied (i.e., utility values) are heterogeneous. In this methodological analysis, we compared the application of utility values among cost–utility models of targeted genetic testing for the prevention of breast and ovarian cancer. While varying utilities on risk-reducing surgeries and cancer states did not impact the cost–utility ratio, utility losses/gains due to a positive/negative test may strongly affect the cost–utility ratio and should be considered mandatory in future models. Because women’s health preferences may have changed as a result of improved oncologic care and genetic counselling, studies for ascertaining women’s health preferences should be updated.

Abstract

Genetic screen-and-treat strategies for the risk-reduction of breast cancer (BC) and ovarian cancer (OC) are often evaluated by cost–utility analyses (CUAs). This analysis compares data on health preferences (i.e., utility values) in CUAs of targeted genetic testing for BC and OC. Based on utilities applied in fourteen CUAs, data on utility including related assumptions were extracted for the health states: (i) genetic test, (ii) risk-reducing surgeries, (iii) BC/OC and (iv) post cancer. In addition, information about the sources of utility and the impact on the cost-effectiveness was extracted. Utility for CUAs relied on heterogeneous data and assumptions for all health states. The utility values ranged from 0.68 to 0.97 for risk-reducing surgeries, 0.6 to 0.85 for BC and 0.5 to 0.82 for OC. In two out of nine studies, considering the impact of the test result strongly affected the cost–effectiveness ratio. While in general utilities seem not to affect the cost–utility ratio, in future modeling studies the impact of a positive/negative test on utility should be considered mandatory. Women’s health preferences, which may have changed as a result of improved oncologic care and genetic counselling, should be re-evaluated.

Population or family history based BRCA gene tests of breast cancer? A systematic review of economic evaluations

BACKGROUND

Nearly 56% of at-risk carriers are not identified and missed as a result of the current family-history (FH) screening for genetic testing. The present study aims to review the economic evaluation studies on BRCA genetic testing strategies for screening and early detection of breast cancer.

METHODS

This systematic literature review is conducted within the Cochrane Library, PubMed, Scopus, Web of Science, ProQuest, and EMBASE databases. In this paper, the relevant published economic evaluation studies are identified by following the standard Cochrane Collaboration methods and adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement reporting some recommendations for articles up to March 2020. Thereafter, the inclusion and exclusion criteria are applied to screen the articles. Disagreements are resolved through a consensus meeting. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist is used in the evaluation of quality. Finally, a narrative synthesis is performed. To compare the different levels of incremental cost-effectiveness ratio (ICER), the net present value is calculated based on a discount rate of 3% in 2019.

RESULTS

Among 788 initially retrieved citations, 12 studies were included. More than 60% of the studies were originated from high-income countries and were published after 2016. It is noteworthy that most of the studies evaluated the payer perspective. Moreover, the robustness of the results were analyzed through one-way and probabilistic sensitivity analyses in nearly 66% of these studies. Nearly, 25% of the studies are focused and defined population-based and family history BRCA tests as comparators; afterwards, the cost-effectiveness of the former was confirmed. The highest and lowest absolute values for the ICERs were $65,661 and $9 per quality adjusted life years, respectively. All studies met over 70% of the CHEERs criteria checklist, which was considered as 93% of high quality on average as well.

CONCLUSIONS

The genetic BRCA tests for the general population as well as unselected breast cancer patients were cost-effective in high and upper-middle income countries and those with prevalence of gene mutation while population-based genetic tests for low-middle income countries are depended on the price of the tests.

Risk factors associated with COVID-19-induced death in patients hospitalized in intensive care units (ICUs) in a city in Southern Brazil

•

Risk factors associated with COVID-19 death after hospitalization were identified.

•

Univariate and multiple logistic regression were performed.

•

Age greater than 60 years and kidney disease were associated with death in patients.

•

Neurological diseases, pneumopathy, and diabetes were also associated with death.

•

This study identifies vulnerable groups and defines vaccination priorities.

Objectives

The aim of this research was to address risk factors associated with death after hospitalization in intensive care units (ICUs) in 728 COVID-19 patients in Londrina, the second most populated city in the State of Paraná – Brazil, between March and December 2020.

Methods

Statistical analysis, including multiple logistic regression was performed to identify risk factors associated with death in these patients.

Results

The results showed that age (60 years or more, O.R. = 3.13, C.I. 95% [2.02; 4.84]), days in the ICU (11 days or more, O.R. = 1.76, C.I. 95% [1.16; 2.66]), neurological diseases (O.R. = 2.15, C.I. 95% [1.07; 4.31]), pneumopathy (O.R = 2.19, C.I. 95% [1.01; 4.82]), diabetes (O.R. = 1.55, C.I. 95% [1.03; 2.32]), and kidney disease (O.R. = 2.27, C.I. 95% [1.18; 4.70]) were associated with increased risk for death from COVID-19.

Conclusion

Knowing the risk factors associated with death after ICUs hospitalization is useful for identifying the most vulnerable groups, as well as for defining vaccination priorities, considering its scarcity in many parts of the world, mainly in underdeveloped countries, including Brazil.

Direct Medical Costs, Productivity Loss Costs and Out-Of-Pocket Expenditures in Women with Breast Cancer in Latin America and the Caribbean: A Systematic Review

OBJECTIVE

Our objective was to conduct a systematic review of the literature to identify, categorise, assess, and synthesise the healthcare costs of patients with breast cancer (BC) and their relatives in Latin America and the Caribbean (LAC).

METHODS

In December 2020, we searched for published data in PubMed, LILACS, EMBASE, and other sources, including the grey literature. Studies were eligible if they were conducted in LAC and reported the direct medical costs, productivity loss costs, out-of-pocket expenditure, and other costs to patients with BC and their relatives. No restrictions were imposed on the type of BC population (metastatic BC or human epidermal growth factor receptor 2-positive/negative BC, among others). We summarised the characteristics and methodological approach of each study and the healthcare costs by cancer stage. We also developed and applied an original ad hoc instrument to assess the quality of the cost estimation studies.

RESULTS

We identified 2725 references and 63 included studies. In total, 79.3% of the studies solely reported direct medical costs and five solely reported costs to patients and their relatives. Only 14.3% of the studies were classified as of high quality. The pooled weighted average direct medical cost per patient-year (year 2020 international dollars [I$]) by BC stage was I$13,179 for stage I, I$15,556 for stage II, I$23,444 for stage III, and I$28,910 for stage IV.

CONCLUSION

This review provides the first synthesis of BC costs in LAC. Our findings show few high-quality costing studies in BC and a gap in the literature measuring costs to patients and their relatives. The high costs associated with the advanced stages of BC call into question the affordability of treatments and their accessibility for patients. Registered in PROSPERO (CRD42018106835).

Why is appropriate healthcare inaccessible for many European breast cancer patients? - The EBCC 12 manifesto

In Europe, inappropriate reimbursement and funding rules and regulations act as disincentives to best breast cancer care or, at worst, hinder best care. This problem was the focus of the 12th European Breast Cancer Conference (EBCC) manifesto, discussed during the virtual conference. As patient involvement is indispensable in driving changes to clinical practice, Europa Donna the European patient advocacy group was closely involved in the 12th manifesto. Reimbursement policies have rarely evolved with advances in breast cancer care such as outpatient (ambulatory) care rather than inpatient admission, use of oral or subcutaneous anti-cancer drugs rather than day-hospital intravenous administration, oncoplastic surgery techniques to minimize mastectomy rates, breast reconstructive surgery, risk-reducing surgery for BRCA mutation carriers, or use of hypo-fractionated breast radiation therapy. Although each European country, region and centre will have to understand how their reimbursement policies may hinder best care and find their own solutions, the problems are similar throughout Europe and some solutions can be broadly applied. This manifesto is not calling for more funding or demanding changes that will result in more expensive care. Reimbursement, if better aligned with guidelines and optimal clinical practice, will deliver more cost-effective healthcare. This will release resources, support more equitable use of finite funding and resources, so allowing more European breast cancer patients to benefit from evidence-based treatment recommended by national and international guidelines.

The role of genomics in global cancer prevention

Despite improvements in the understanding of cancer causation, much remains unknown regarding the mechanisms by which genomic and non-genomic factors initiate carcinogenesis, drive cell invasion and metastasis, and enable cancer to develop. Technological advances have enabled the analysis of whole genomes, comprising thousands of tumours across populations worldwide, with the aim of identifying mutation signatures associated with particular tumour types. Large collaborative efforts have resulted in the identification and improved understanding of causal factors, and have shed light on new opportunities to prevent cancer. In this new era in cancer genomics, discoveries from studies conducted on an international scale can inform evidence-based strategies in cancer control along the cancer care continuum, from prevention to treatment. In this Review, we present the relevant history and emerging frontiers of cancer genetics and genomics from the perspective of global cancer prevention. We highlight the importance of local context in the adoption of new technologies and emergent evidence, with illustrative examples from worldwide. We emphasize the challenges in implementing important genomic findings in clinical settings with disparate resource availability and present a conceptual framework for the translation of such findings into clinical practice, and evidence-based policies in order to maximize the utility for a population.