Cost-Effectiveness of Adjuvant Olaparib for Patients With Breast Cancer and Germline BRCA1/2 Mutations

Importance

The OlympiA trial found that 1 year of adjuvant olaparib therapy can improve distant disease-free survival and overall survival from early-stage breast cancer in patients with a germline BRCA1/2 mutation. However, olaparib, an oral poly-adenosine diphosphate ribose polymerase inhibitor, is estimated to cost approximately $14 000 per month in the US.

Objective

To estimate the incremental cost-effectiveness of adjuvant olaparib compared with no olaparib in eligible patients.

Design, Setting, and Participants

In an economic evaluation from a health care system perspective, the cost-effectiveness of adjuvant olaparib was analyzed using a Markov state-transition model. The model simulated costs and lifetime health outcomes of 42-year-old women with high-risk early-stage breast cancer and a known BRCA1/2 mutation who completed definitive primary therapy and neoadjuvant or adjuvant systemic therapy. The study was conducted from August 2021 to July 2023. The effectiveness of olaparib was based on the findings of the OlympiA randomized clinical trial, and other model parameters were identified from the literature. The model was calibrated to the 1-, 2-, 3-, and 4-year distant disease-free and overall survival observed in the OlympiA trial, and olaparib was assumed to reduce the risk of distant recurrence only in the first 4 years.

Exposure

One year of adjuvant olaparib or no adjuvant olaparib.

Main Outcome and Measure

Incremental cost-effectiveness ratio (ICER) in 2021 US dollars per quality-adjusted life-year (QALY) gained. All outcomes were discounted by 3% annually.

Results

In the base case, adjuvant olaparib was associated with a 1.25-year increase in life expectancy and a 1.20-QALY increase at an incremental cost of $133 133 compared with no olaparib. The resulting ICER was approximately $111 000 per QALY gained. At a willingness-to-pay threshold of $150 000 per QALY, olaparib was cost-effective at its 2021 price and in more than 92% of simulations in probabilistic sensitivity analysis. The results were sensitive to assumptions about the effectiveness of olaparib and quality of life for patients with no disease recurrence.

Conclusions and Relevance

In this study, from a US health care system perspective, adjuvant olaparib was a cost-effective option for patients with high-risk, early-stage breast cancer and a germline BRCA1/2 mutation.

Universal genetic testing for women with newly diagnosed breast cancer in the context of multidisciplinary team care

OBJECTIVE

To determine the feasibility of universal genetic testing of women with newly diagnosed breast cancer, to estimate the incidence of pathogenic gene variants and their impact on patient management, and to evaluate patient and clinician acceptance of universal testing.

DESIGN, SETTING, PARTICIPANTS

Prospective study of women with invasive or high grade in situ breast cancer and unknown germline status discussed at the Parkville Breast Service (Melbourne) multidisciplinary team meeting. Women were recruited to the pilot (12 June 2020 - 22 March 2021) and expansion phases (17 October 2021 - 8 November 2022) of the Mutational Assessment of newly diagnosed breast cancer using Germline and tumour genomICs (MAGIC) study.

MAIN OUTCOME MEASURES

Germline testing by DNA sequencing, filtered for nineteen hereditary breast and ovarian cancer genes that could be classified as actionable; only pathogenic variants were reported. Surveys before and after genetic testing assessed pilot phase participants' perceptions of genetic testing, and psychological distress and cancer-specific worry. A separate survey assessed clinicians' views on universal testing.

RESULTS

Pathogenic germline variants were identified in 31 of 474 expanded study phase participants (6.5%), including 28 of 429 women with invasive breast cancer (6.5%). Eighteen of the 31 did not meet current genetic testing eligibility guidelines (probability of a germline pathogenic variant ≥ 10%, based on CanRisk, or Manchester score ≥ 15). Clinical management was changed for 24 of 31 women after identification of a pathogenic variant. Including 68 further women who underwent genetic testing outside the study, 44 of 542 women carried pathogenic variants (8.1%). Acceptance of universal testing was high among both patients (90 of 103, 87%) and clinicians; no decision regret or adverse impact on psychological distress or cancer-specific worry were reported.

CONCLUSION

Universal genetic testing following the diagnosis of breast cancer detects clinically significant germline pathogenic variants that might otherwise be missed because of testing guidelines. Routine testing and reporting of pathogenic variants is feasible and acceptable for both patients and clinicians.

Multimodality Therapy in Patients With Primary Pericardial Mesothelioma

INTRODUCTION

Primary pericardial mesothelioma (PPM) has no accepted standard-of-care treatment options with management and outcomes often extrapolated from diffuse pleural mesothelioma. Disease-specific research is needed to better define PPM. We report our institutional experience with PPM highlighting the potential role for multimodality therapy.

METHODS

Patients with PPM diagnosed by a multidisciplinary team of medical oncologists, thoracic surgeons, thoracic pathologists, and radiologists between January 2011 and January 2022 were followed to February 2022. Clinicopathologic features and treatment outcomes were annotated. Overall survival (OS) was defined from the date of pathologic diagnosis.

RESULTS

The median age at diagnosis of the 12 patients identified with having PPM was 51 (range: 21-71) years old. Most patients were of female sex (n = 8; 67%), 75% of the samples were epithelioid (n = 9), and 25% were nonepithelioid (two sarcomatoid and one biphasic). Most cases (92%, 11 of 12) had expression of at least two mesothelial markers on immunohistochemistry. The median OS of the cohort was 25.9 months. Five patients had an OS greater than 12 months; four of whom received pericardial radiation. Three of the patients who received radiation did so as part of a trimodality approach (surgical resection, adjuvant chemotherapy, and radiation); the OS for patients who received trimodality therapy was 70.3 months versus 8.2 months for those who did not.

CONCLUSIONS

PPM represents a distinct disease with no universally accepted treatment options. Our findings suggest that trimodality therapy may improve outcomes in selected patients with PPM.

Abstract P3-09-02: Mutational assessment of newly diagnosed breast cancer using Germline and tumor genomICs

Background :For patients with newly diagnosed breast cancer, real-time identification of pathogenic germline mutations in hereditary breast cancer (HBC) genes can provide important information to inform decisions regarding surgery, medical oncology, radiation oncology and to enable activate risk mitigation strategies for unaffected relatives. The potential to dramatically improve outcomes by identifying HBC gene mutation carriers at diagnosis has been demonstrated in the OlympiA. The current strategy of offering germline testing based on NCCN guidelines or validated scores inherently fails to identify all patients with germline HBC gene mutations with adverse consequences for patients and their families. Also, in about 15% of patients without HBC gene mutations, the breast tumors have characteristics suggestive of a more aggressive course. Although universal HBC gene testing has been reported for sub-types of breast cancer or at specialist centers, the MAGIC study is the first prospective trial of unselected invasive breast cancers in general practice combining upfront germline and somatic sequencing with well-validated methods to assess the acceptability of universal testing to patients and clinicians. Methods :This is an Australian multi-center prospective study with 150 consecutive consented patients who are newly diagnosed with nonmetastatic breast cancers. High-grade ductal carcinoma in-situ and pleomorphic lobular cancers were included. Germline testing was performed by whole genome sequencing on DNA from blood or saliva and the data analyzed for actionable HBC gene mutations, including large genomic rearrangements. Whole genome Tumor sequencing was performed on DNA extracted from formalin fixed paraffin-embedded diagnostic tumor and the data analyzed for actionable somatic mutations as well as scoring for homologous recombination deficiency using HRDetect and mutational signatures. The frequency of actionable HBC gene mutations and the number of additional carriers identified compared to standard referral guidelines was the primary objective. For additional analysis, a 3-generation pedigree was done and NCCN, MANCHESTER, and BOADICEA scores were calculated to see whether they would qualify for germline testing according to American and Australian guidelines. Well validated questionnaires were given pre and post-testing for all patients to assess the favorability of universal testing. Health economic analysis will be performed to see the cost vs benefit of offering germline testing. Results :A total of 12 carriers of actionable germline mutations were identified (8.0%) in BRCA1 (n=2), BRCA2 (n=1), PALB2 (n=3), CHEK2 (n=2), ATM (n=2) and PMS2 (n=2). No actionable HBC germline mutations were identified in the 14 cases diagnosed with DCIS only. Only 3 of the 12 mutation positive cases (25%) were referred by the treating clinician for germline testing and including BOADICEA and MANCHESTER scores, would only have identified 6 cases (50%) eligible for germline testing. 9/12 (75%) cases were ER positive including 4 carriers of BRCA1, BRCA2 or PALB2 mutations. Preliminary ascertainment of patient acceptance demonstrates >90% were in favor of universal testing. Among the 12 HBOC gene mutation carriers, the study changed the surgical recommendation for 7 patients (58%) which included the recommendation of B/L salpingo-oophorectomy and radiation management for 3 (25%) patients. Conclusion :Universal germline HBC gene testing is the best method for detecting carriers as over 50% are missed using current. Identifying an actionable mutation in real-time can inform the decision in all specialties involved in the treatment and has a high rate of impacting the clinical decision-making process. This approach was favored by the patients and the clinicians and provided a pathway forward for breast cancer management.

Citation Format: Dilanka L De Silva, Anita R Skandarajah, Michelle Sinclair, Maira Kentwell, Lisa Devereux, Magnus Zeethoven, Kirsten Hogg, Luxi Lal, Lesley Stafford, Paul A James, Geoffrey J Lindeman, Gregory B Mann, Ian G Campbell. Mutational assessment of newly diagnosed breast cancer using Germline and tumor genomICs [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-09-02.

Is CHEK2 a moderate-risk breast cancer gene or the younger sister of Li-Fraumeni?

The CHEK2 gene is mostly considered as a moderate breast cancer gene with the result that many clinicians have a narrow focus. We present the 10-year journey of a man who had five different cancers and had iterative genetic testing including for Li-Fraumeni syndrome, eventually to discover a pathogenic variant in the CHEK2 gene, possibly explaining his numerous cancers. This diagnosis offered him closure which he had desperately sought for well over a decade. A pathogenic variant in the CHEK2 gene can potentially explain these cancers because of its function as a tumour suppressor gene. Consideration is warranted of what this means for individuals with CHEK2 variants who may develop multiple cancers, their prognosis and whether different treatment modalities such as chemotherapy, radiotherapy or target agents would need modification. We encourage more research into the many faces of the CHEK2 gene and the potential for predisposition to multiple cancers.