DENVER, May 19, 1997-Prophylactic mastectomy and oophorectomy (removal of the ovaries) for women who carry the BRCA1 mutation and have a family history of breast and ovarian cancer can prolong life expectancy by approximately 8.5 years, but at a great cost to quality of life, concludes a new study by researchers at Columbia-Presbyterian Medical Center. The findings were presented today at the American Society of Clinical Oncology annual meeting in Denver, Col. The study also concludes that prophylactic surgery is cost effective compared to the cost of cancer treatments and should be covered by insurance companies.
Dr. Victor R. Grann, director of health outcomes research at Columbia-Presbyterian's Herbert Irving Comprehensive Cancer Center, and colleagues based their findings on survival data from 1.6 million cancer cases covering 10 percent of the U.S. population. Using this data, they developed a decision analysis computer model for a healthy 30-year-old woman who has been diagnosed with the BRCA1 gene and has a family history of breast and ovarian cancer. Women with BRCA1 mutations from high-risk families may have an 85 percent risk of developing breast cancer and a 63 percent risk of developing ovarian cancer by age 70. Dr. Grann's model compares the effects of a prophylactic oophorectomy, or prophylactic mastectomy with oophorectomy, to only surveillance on survival time, quality of life, and cost effectiveness.
The study found that a 30-year-old woman with the BRCA1 gene who comes from a high-risk family and has a prophylactic oophorectomy would be expected to live 4.1 years longer than a women who did not have the procedure. A prophylactic oophorectomy and mastectomy increases survival by 8.5 years.
This study differs from the recently published article in the New England Journal of Medicine in that its results are based on data only from high-risk women with the BRCA1 gene who have at least four first-degree relatives with breast or ovarian cancer, in which case the risks of developing cancer are more accepted. The researchers also measured the effect of the three interventions on quality adjusted life years, a common statistical measurement that attempts to take into account the impact of disease and treatment on daily happiness, self-image, physical comfort, for example. They found that a woman living with the physical and emotional effects of having her breasts and ovaries removed at age 30 gained only one quality-adjusted-life-year compared to a woman who chose not to have the procedures. A quality adjusted life year is defined as one year of perfect health.
"These figures show that many women will not gain that much in terms of quality of life by choosing prophylactic surgery over surveillance," says Dr. Grann. "Yes, you can prolong your survival with surgery. Eight years of life is a lot of additional life years. But these are difficult procedures in terms of quality of life for a 30-year-old woman who will have to go through life without breasts or ovaries. The impact on happiness and self-image is the tradeoff. It would be understandable if she wanted to avoid prophylactic surgery."
Finally, the study found prophylactic surgery to be more cost effective than other related medical treatments. Prophylactic oophorectomy cost $888 per quality-adjusted life year; prophylactic oophorectomy and mastectomy cost $4,276 per quality-adjusted life year. In contrast, chemotherapy for a 45-year-old with breast cancer that had not spread to her lymph nodes cost $15,400 per quality-adjusted life year. Autologous bone marrow transplantation for metastatic breast cancer cost $27,300 per quality-adjusted life year.
"This shows insurance companies that the cost effectiveness of prophylactic surgery is reasonable compared to other procedures that they already pay for," says Dr. Grann. "It makes sense for insurance companies to pay for this prophylactic surgery."
Dr. Grann concludes that this work is preliminary and hopefully new methods of treatment will evolve that will make prophylactic surgery obsolete.
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