## Clinical program is cost-effective for managing BRCA carriers long-term

Breast cancer is the second most common cancer among American women. For the average woman in the United States, the risk of developing the disease is about 13%. However, for women who carry pathogenic variants in BRCA1 or BRCA2, cumulative breast cancer risk jumps to between 61% and 79%. The genetic variants also predispose women to ovarian cancer. Although genetic testing for the variants is on the rise, studies demonstrating health outcomes and cost-effectiveness of clinical practices designed to manage patients identified as high risk remains insufficient. In this issue, Petelin and colleagues demonstrate that within a structured clinical program, long-term management of unaffected BRCA1/2 carriers is cost-effective. Drawing on clinical and cost data from a tertiary hospital database of 983 identified BRCA1/2 carriers, the researchers used a microsimulation model to estimate lifetime health outcomes and health-care costs within the Australian public health-care system. Women with no history of cancer or prior risk management entered the simulation at age 20 and were followed to age 100. The model simulated breast and ovarian cancer development but did not include recurrence or remission. Treatment intervention included participation in a multidisciplinary high-risk clinic in conjunction with risk-management strategies including annual breast screening and risk-reducing surgery. Compared with a “do nothing” approach, the intervention proved clinically more effective and also cost more. With a willingness-to-pay threshold of AUD$50,000 per quality-adjusted life-year, the intervention was cost-effective, with an incremental cost-effective ratio of AUD$32,359 for BRCA1 carriers and AUD\$48,263 for BRCA2 carriers. The authors conclude that a familial cancer service is a cost-effective approach for the long-term clinical management of BRCA1/2 carriers, but caution that the results may not be generalizable given differences between health-care systems. –V. L. Dengler, News Editor