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Radiology. Mar 2010; 254(3): 793–800.
Published online Feb 8, 2010. doi:  10.1148/radiol.09091086
PMCID: PMC2826703

Cost-effectiveness of Breast MR Imaging and Screen-Film Mammography for Screening BRCA1 Gene Mutation Carriers1

Abstract

Purpose:

To evaluate the clinical effectiveness and cost-effectiveness of screening strategies in which MR imaging and screen-film mammography were used, alone and in combination, in women with BRCA1 mutations.

Materials and Methods:

Because this study did not involve primary data collection from individual patients, institutional review board approval was not needed. By using a simulation model, we compared three annual screening strategies for a cohort of 25-year-old BRCA1 mutation carriers, as follows: (a) screen-film mammography, (b) MR imaging, and (c) combined MR imaging and screen-film mammography (combined screening). The model was used to estimate quality-adjusted life-years (QALYs) and lifetime costs. Incremental cost-effectiveness ratios were calculated. Input parameters were obtained from the medical literature, existing databases, and calibration. Costs (2007 U.S. dollars) and quality-of-life adjustments were derived from Medicare reimbursement rates and the medical literature. Sensitivity analysis was performed to evaluate the effect of uncertainty in parameter estimates on model results.

Results:

In the base-case analysis, annual combined screening was most effective (44.62 QALYs), and had the highest cost ($110973), followed by annual MR imaging alone (44.50 QALYs, $108641), and annual mammography alone (44.46 QALYs, $100336). Adding annual MR imaging to annual mammographic screening cost $69125 for each additional QALY gained. Sensitivity analysis indicated that, when the screening MR imaging cost increased to $960 (base case, $577), or breast cancer risk by age 70 years decreased below 58% (base case, 65%), or the sensitivity of combined screening decreased below 76% (base case, 94%), the cost of adding MR imaging to mammography exceeded $100000 per QALY.

Conclusion:

Annual combined screening provides the greatest life expectancy and is likely cost-effective when the value placed on gaining an additional QALY is in the range of $50000–$100000.

© RSNA, 2010

Supplemental material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09091086/-/DC1

Introduction

Women with BRCA1 or BRCA2 gene mutations have a substantially increased lifetime risk of developing breast cancer (14). Although screening mammography is the current clinical standard for breast cancer screening in the general population, it aids in the detection of less than one-half of prevalent and incident breast cancers in high-risk women (57). This finding is thought to be related to multiple factors, such as the younger age at screening and increased breast density in these women, as well as to pathologic and imaging characteristics of breast cancers in this population (812).

Breast magnetic resonance (MR) imaging is highly sensitive, depicts many cancers not seen at mammography (1319), and is recommended as an adjunct to mammography for screening women at increased genetic risk of breast cancer (20). Compared with mammography, breast MR imaging is more time consuming and more expensive. Further, MR imaging is less specific, which will invariably result in an increased number of false-positive test results. It is presumed that early detection with MR imaging decreases breast cancer mortality, although there is currently insufficient evidence to confirm this finding. A randomized controlled trial in which screening with the two modalities is compared is unlikely to be performed, because of the large number of women and length of follow-up required, as well as the expense that would be incurred. In the absence of a definitive randomized controlled trial to establish the comparative effectiveness of multimodality breast cancer screening, we have developed a computer simulation model of breast cancer natural history and outcomes to project long-term health outcomes and lifetime costs related to breast cancer screening with MR imaging.

The purpose of this study was to evaluate the clinical effectiveness and cost-effectiveness of screening strategies in which MR imaging and screen-film mammography were used, alone and in combination, in women with BRCA1 gene mutations.

Materials and Methods

Because this study did not involve primary data collection from individual patients, institutional review board approval was not needed.

Cost-effectiveness Analysis

We used standard cost-effectiveness analytic methods as recommended by the Panel on Cost-Effectiveness in Health and Medicine (21) by using a computer simulation model to project health outcomes and costs from a societal perspective over a lifetime horizon. Screening strategies were compared in an incremental cost-effectiveness analysis. The strategies were ranked in order of increasing effectiveness and then in order of increasing cost. Dividing the difference in cost (incremental cost) by the difference in health outcome (incremental effectiveness, measured in quality-adjusted life-years [QALYs]) provides the incremental cost-effectiveness ratio (ICER), which describes the cost required to obtain one additional QALY by using the next more effective strategy. Lifetime costs were measured in 2007 U.S. dollars. A 3% annual discount rate was applied to both costs and QALYs.

Screening Strategies Evaluated

Details of the model have previously been reported (22), and an overview is provided in Appendix E1 (online). Three annual screening strategies were evaluated relative to a strategy of clinical surveillance without imaging, as follows: (a) screen-film mammography, (b) MR imaging, and (c) combined mammography and MR imaging (hereafter called combined screening). All screening strategies began at age 25 years, on the basis of the recommendations of the Cancer Genetics Studies Consortium (23) and the National Comprehensive Cancer Network (24). For women undergoing combined screening, we assumed that both tests were performed contemporaneously. Reflecting current clinical practice, a positive result with either mammography or MR imaging was considered a positive combined screening result.

The diagnosis of cancer included a three-stage testing sequence of screening, diagnostic work-up, and biopsy. Women with positive screening results underwent further diagnostic work-up, which consisted of additional mammographic views, with or without breast ultrasonography. Women whose diagnostic work-up results were negative or benign were tracked as having had false-positive screening examination results. Women whose diagnostic work-up results were suspicious for malignancy subsequently underwent biopsy to establish a final diagnosis of malignant or benign disease. We assumed that women with cancer who had a true-positive screening result also had positive diagnostic work-up findings, leading to a recommendation for biopsy. Among women without cancer, the probability of a biopsy recommendation after diagnostic work-up was assumed to be conditionally independent of the initial screening test results. If the biopsy results demonstrated benign disease, the woman was tracked as having had both a false-positive screening examination and a false-positive biopsy. Women with negative screening results underwent no further intervention until the next screening event. If a cancer was missed on a screening test (false-negative result), cancer progression continued until the next screening event or until the cancer manifested clinically as an interval cancer.

Model Input Parameters

Input parameters were identified through a critical review of the medical literature and publicly available databases (2527). Many key model parameters have been previously reported (22). As part of the ongoing model refinement process, the model was recalibrated by using a simulated annealing algorithm (28) to identify values for several natural history parameters (Appendix E1, Tables E1, E2 [online]). The sensitivity of screen-film mammography, MR imaging, and combined screening (Table E3 [online]), stratified according to cancer invasiveness and size, as well as the specificity of each screening modality (Table E4 [online]), were obtained from a multicenter trial of women at increased familial risk for breast cancer (13). Costs related to screening and diagnosis were derived from 2007 Medicare reimbursement rates (26). Additional costs of care, patient time costs, and quality-of-life weights were derived from the medical literature (Tables E5, E6 [online]). Costs from years prior to 2007 were adjusted to 2007 U.S. dollars by using the medical care component of the consumer price index (29). In the base case, quality-of-life weights for women with breast cancer were applied for 5 years, at which time their quality-of-life weight reverted to that of a healthy, cancer-free woman of the same age. In the base case, no short-term quality-of-life decreases related to breast cancer screening or false-positive test results were incorporated.

Outcomes

Primary outcomes projected were: (a) lifetime costs, (b) QALYs, and (c) ICERs for each screening strategy. Additional long-term health outcomes projected were as follows: absolute life expectancy gain and breast cancer mortality reduction obtained with each screening strategy. Intermediate health outcomes evaluated included the following: mean age at diagnosis, mean diameter of invasive cancers, and stage distribution of cancers detected with each screening strategy. The diagnostic consequences of screening that we evaluated were the percentage of women with one or more false-positive screening test results in their lifetimes, the percentage of women with one or more false-positive biopsy results, and the frequency distribution of false-positive test results. The relationship between false-positive screening test results and breast cancer mortality reduction was examined by calculating the number of additional false-positive screening test results required to prevent a breast cancer death.

Sensitivity Analysis

We analyzed the model as a Markov Monte Carlo simulation to examine first-order uncertainty, which characterizes the random variability in individual outcomes conditional on underlying parameter values. We examined the effect of second-order uncertainty, which characterizes the imprecision of knowledge in regard to parameter values, by performing univariate threshold-level sensitivity analysis to identify parameters that had values that could cause the ICER for annual combined screening either to decrease below $50000 per QALY or to increase above $100000 per QALY. Parameters examined over a plausible clinical range included mutation penetrance, diagnostic test performance of screening, costs of screening and diagnosis, annual discount rate, and quality-of-life weights for women with breast cancer.

Sensitivity analyses also were used to evaluate diagnostic test performance. In multivariate sensitivity analyses, paired sensitivity and specificity values for annual combined screening were obtained from published trials of multimodality screening in women at increased genetic risk (15,17). We also used points along a breast MR imaging summary receiver operating characteristic curve (30) as a plausible lower bound for sensitivity and specificity values of the annual combined strategy. Although Leach et al (13) reported no increase in specificity between initial and subsequent screening examinations, other investigators (15,31) have reported such an increase. We, therefore, performed additional sensitivity analyses, assuming a 5% increase in specificity for subsequent screening for each modality.

To examine the potential effect of risk-reducing prophylactic oophorectomy (32,33), we performed sensitivity analyses in which the risk of breast cancer was reduced by 50%, following prophylactic oophorectomy at ages 35, 40, or 45 years. Accordingly, the mortality risk from ovarian cancer was subsequently subtracted from a woman’s age-specific nonbreast cancer mortality risk. Because transient quality-of-life effects have been shown to affect the results of cost-effectiveness analyses of breast cancer screening (3436) and quality-of-life weights for breast biopsy have been identified (37), these short-term quality-of-life effects were included in the sensitivity analysis (Table E7 [online]).

Results

Health Outcomes

Model projections indicated that all annual screening strategies helped improve intermediate outcomes, with identification of more cancers at an earlier age and smaller size (Table 1). Of the three screening strategies evaluated, annual combined screening was best at depicting early-stage cancers. With this strategy, the median invasive cancer diameter was 1.1 cm, and approximately 80% of diagnosed cancers were in situ or node negative in stage. Long-term outcomes also improved with screening. Average cohort life expectancy increased with screening, with the greatest gain seen with annual combined screening. At every age, screening helped reduce breast cancer mortality (Fig 1), with the greatest relative mortality reduction (22.3%) achieved with annual combined screening.

Table 1
Screening Strategy Outcomes
Figure 1:
Cumulative breast cancer mortality according to screening strategy. Ann Mammo = annual screen-film mammography, Ann MRI = annual MR imaging, Ann Combined = annual ...

Screening with MR imaging also was associated with a high rate of false-positive test results (Table 2). With MR imaging screening, most of the women undergoing screening had one or more false-positive screening examination results during their lives (MR imaging alone, 87.9%; combined screening, 90.5%). Of these women, approximately one-half were recalled for further evaluation four or more times during their lives (MR imaging alone, 46.1%; combined screening, 54.5%). In addition, more than 33% of women who underwent MR imaging screening also underwent biopsies with benign results.

Table 2
False-Positive Results according to Screening Strategy

Table 3 presents the relationship between false-positive test results and breast cancer mortality reduction. With annual mammographic screening, 37 false-positive screening examination results occurred for every breast cancer death averted. When annual MR imaging was added to annual mammographic screening, 137 additional false-positive screening examination results occurred for each additional life saved.

Table 3
Relationship between False-Positive Screening Results and Mortality Reduction

Cost-effectiveness Analysis

In cost-effectiveness analysis, screening strategies were ranked in order of increasing QALYs and then cost (Table 4). Annual combined screening was the most effective, producing 44.624 QALYs, and also had the highest lifetime cost ($110973). ICERs were calculated to determine the cost required to gain one additional QALY by using the next more effective strategy. Because the ICER for annual MR imaging screening was higher than that of the next more effective screening strategy (annual combined screening), it was eliminated from consideration by extended dominance (21). The ICERs for the remaining strategies were then recalculated. The ICER for annual mammographic screening versus clinical surveillance alone was $16751 per additional QALY gained. The cost of annual combined screening versus annual mammographic screening was $69125 per QALY.

Table 4
Cost-effectiveness of Screening

Sensitivity Analyses

Univariate sensitivity analysis results indicated that the ICER for annual combined screening was influenced by assumptions in regard to breast MR imaging cost and mutation penetrance (Table 5). Varying the cost for breast MR imaging caused the ICER for annual combined screening to vary over the widest range. As this cost decreased from the base-case value of $577 to the threshold value of $433, the ICER for annual combined screening decreased to, and then decreased below, $50000 per QALY. As the cost for screening breast MR imaging increased to the threshold value of $960, the ICER for annual combined screening increased and then exceeded $100000 per QALY.

Table 5
Threshold-level Sensitivity Analysis Results

Annual combined screening also became more cost-effective as breast cancer risk increased and became less cost-effective as risk decreased. The ICER of annual combined screening decreased to less than $50000 per QALY when mutation penetrance increased from 65% to 71% and exceeded $100000 per QALY when mutation penetrance decreased below 48%. Results of sensitivity analyses for evaluation of the potential effect of risk-reducing prophylactic oophorectomy at varying ages demonstrated a similar effect. When prophylactic oophorectomy was performed at age 45 years for all women in the cohort, the subsequent decrease in both risk and competing mortality caused the ICER for annual combined screening to increase from the base-case value of $69125 to $95643 per QALY. With prophylactic oophorectomy at age 40 years, the ICER for annual combined screening exceeded $100000 per QALY and continued to increase with surgery at earlier ages.

The cost-effectiveness of annual combined screening was also influenced by estimates of diagnostic test performance. For most sensitivity-specificity pairs evaluated, the ICER for annual combined screening remained between $50000 and $100000 per QALY (Fig 2). It was only at an extreme portion of the receiver operating characteristic curve, where the sensitivity of combined screening decreased below 76%, that the ICER exceeded $100000 per QALY. The ICER also remained between $50000 and $100000 per QALY when the specificity for each modality during incident screening rounds was increased by 5%. Additional sensitivity analyses of costs, annual discount rate, quality-of-life weights, and natural history parameter values were performed, all of which yielded ICER values less than $100000 per QALY (Appendix E1 [online]).

Figure 2:
Sensitivity analysis of diagnostic test performance. ICER for annual combined screening remained within range of $50000–$100000 per QALY for most sensitivity and specificity pairs examined, ...

Discussion

The results of this analysis suggest that breast cancer screening outcomes for women with BRCA1 gene mutations can be improved through annual combined screening with screen-film mammography and MR imaging. When we compared three annual screening strategies, breast cancers were identified at smaller sizes and earlier stages and the greatest breast cancer mortality reduction was provided with combined screening. These results also highlight an important trade-off related to screening with MR imaging: an increased rate of false-positive test results. Our study provides a quantitative point estimate and frequency range of false-positive screening results, as well as their relationship to breast cancer mortality reduction. When annual MR imaging was added to annual mammographic screening, model projections of the number of additional false-positive screening test results incurred to avert a death from breast cancer increased from 37 to 137. These findings can be placed in the context of a survey by Schwartz et al (38) of women’s preferences in regard to mammographic screening. In the study of Schwartz et al, 63% of women aged 18–97 years with no personal history of breast cancer indicated that they would accept 500 or more false-positive screening test results to avert a death from breast cancer. Thus, for women with BRCA1 gene mutations, whose risk of breast cancer is much higher than that of the general population, the benefits of intensive surveillance for breast cancer are likely to outweigh the effects of false-positive screening results projected by our model.

When cost-effectiveness analysis was used to compare screening strategies, the most effective strategy, annual combined screening, was also the most costly. In the base-case analysis, the cost to gain an additional QALY through annual combined screening when compared with annual mammography alone was $69125 per QALY. Annual MR imaging was more cost-effective when added as an adjunct to annual mammography rather than as a replacement. These findings suggest that the current screening recommendations for women at increased genetic risk of breast cancer from the American Cancer Society (20) are likely cost-effective.

Cost-effectiveness analysis provides a method for comparing the relative value of alternative interventions to improve health outcomes. Although no current consensus exists on a single dollar-per-QALY threshold value for defining whether an intervention can be considered cost-effective in the United States, commonly identified threshold values range from $50000 to $100000 per QALY (39,40). Applying this range to our base-case results, annual combined screening would likely be considered cost-effective (at $69125 per QALY).

Another frequently applied approach to evaluating the potential cost-effectiveness of an intervention involves comparison with other accepted clinical practices. A cost-effectiveness analysis (36) of mammographic screening for women aged 40 years and older, on the basis of actual U.S. screening patterns, yielded an estimated ICER of $37058 per QALY in 2000 U.S. dollars compared with no mammographic screening, which is equivalent to an ICER of $49883 in 2007 U.S. dollars, after adjusting for inflation. Cost-effectiveness analyses of breast cancer screening focusing on subgroups within the general population have demonstrated higher ICERs (less cost-effective). A cost-effectiveness analysis (41) of adding annual mammographic screening for women aged 40–49 years to annual screening for women aged 50–69 years yielded an ICER of $168400 per QALY in 1995 U.S. dollars ($268107 in 2007 U.S. dollars). Kerlikowske et al (42) estimated that the ICER for annual mammographic screening for women up to age 79 years was $73855 per year of life saved in 1998 U.S. dollars ($107092 in 2007 U.S. dollars).

In the closest direct comparison with our results, Plevritis et al (35) estimated that the ICER for adding annual MR imaging to annual mammographic screening for women with BRCA1 mutations aged 25–69 years is $88705 per QALY ($96422 per QALY in 2007 U.S. dollars), compared with our result of $69125 per QALY. The incremental benefit in our analysis is more conservative than that of Plevritis et al, which is probably related to differing structural assumptions in the model, particularly those related to the natural history of ductal carcinoma in situ. The incremental costs in our analysis are also lower, probably related to differences in the sources for treatment costs and in how these costs were applied. Given the differences in model structure and underlying assumptions, the ICER estimates from our study and the study of Plevritis et al are roughly comparable. Because a definitive randomized controlled trial is unlikely to be performed, results such as these from different models may be valuable contributions to the developing consensus in regard to the long-term clinical effectiveness and cost-effectiveness of breast cancer screening with MR imaging.

The projected cost-effectiveness of annual combined screening is strongly dependent on the cost of an MR imaging examination and the underlying breast cancer risk in the women being screened. Variations in MR imaging cost could shift the ICER for annual combined screening from less than $50000 per QALY to more than $100000 per QALY. Similarly, annual combined screening was more cost-effective with increasing risk and less so with decreasing risk, because of either variation in mutation penetrance or prophylactic oophrectomy. It is important to note that the decision to undergo risk-reducing prophylactic oophorectomy is an individual one, which is based on a woman’s personal preferences, goals, and level of risk tolerance. Even after prophylactic oophorectomy, our model projected that screening with annual combined mammography and MR imaging resulted in increased life expectancy and quality-adjusted life expectancy beyond that attainable with annual mammography alone.

Although the diagnostic test performance of the annual combined screening also had the potential to affect its cost-effectiveness, sensitivity for combined screening would have to be less than 76% (at the extreme end of the range of clinically plausible values) to increase the ICER beyond $100000 per QALY.

Two potential limitations of our study were based on our choices for input parameter values. For some model parameter values, we extrapolated data from the general population to the BRCA1 mutation carrier population. Whenever possible, parameter estimates specific to BRCA1 mutation carriers were used. However, in some instances we based input parameter estimates on sources with larger sample sizes in the general population (25,27,43). We also used Medicare reimbursement (26) as a proxy for diagnostic costs, even though many women with BRCA1 mutations undergoing screening are younger than 65 years, because Medicare estimates are the most generalizable among those of major health care payers (21).

For the combined screening strategy in this analysis, the two tests were assumed to be performed contemporaneously on an annual basis, as performed in multimodality screening trials (1317). Consideration of screening with MR imaging and mammography at alternating 6-month intervals also has been advocated (44). Although not included in this analysis, modeling efforts to evaluate the comparative effectiveness of alternating and annual combined screening with MR imaging and mammography are under way.

In summary, annual combined screening for BRCA1 mutation carriers provides the greatest life expectancy gain and is likely cost-effective, when the value placed on gaining an additional QALY is in the range of $50000–$100000. The benefits of screening with increased intensity for these women are likely to outweigh the effects of false-positive screening results.

Advances in Knowledge

  • When three annual screening strategies were compared, combined screening with MR imaging and screen-film mammography provided the greatest life expectancy gain and breast cancer mortality reduction and was also the most costly.
  • Annual MR imaging was more cost-effective as an adjunct to annual mammographic screening rather than as a replacement.
  • The projected cost-effectiveness of annual combined screening with MR imaging and screen-film mammography is strongly dependent on the cost of an MR imaging examination and the underlying breast cancer risk in the women being screened.

Implications for Patient Care

  • The results of this analysis suggest that breast cancer screening outcomes for women with BRCA1 gene mutations can be improved through annual combined screening with screen-film mammography and MR imaging.
  • Compared with annual mammography alone, annual combined screening for BRCA1 gene mutation carriers is likely cost-effective when the value placed on gaining an additional quality-adjusted life-year is in the range of $50000–$100000.

Supplementary Material

Appendix E1:

Acknowledgments

We thank the Breast Cancer Surveillance Consortium for providing deidentified data used during model calibration and as model input parameters.

Received June 20, 2009; revision requested August 19; final revision received September 17; final version accepted September 30.

Funding: This research was supported by the National Cancer Institute (grant K07CA128816) and the Breast Cancer Surveillance Consortium (grants U01CA63740, U01CA86082, U01CA63736, U01CA70013, U01CA69976, U01CA63731, U01CA70040).

Authors stated no financial relationship to disclose.

Abbreviations:

ICER
incremental cost-effectiveness ratio
QALY
quality-adjusted life-year

References

1. Antoniou A, Pharoah PD, Narod S, et al. Average risks of breast and ovarian cancer associated with BRCA1 or BRCA2 mutations detected in case series unselected for family history: a combined analysis of 22 studies. Am J Hum Genet 2003;72:1117–1130 [PMC free article] [PubMed]
2. Easton DF, Ford D, Bishop DT. Breast and ovarian cancer incidence in BRCA1-mutation carriers. Breast Cancer Linkage Consortium. Am J Hum Genet 1995;56:265–271 [PMC free article] [PubMed]
3. Ford D, Easton DF, Bishop DT, Narod SA, Goldgar DE. Risks of cancer in BRCA1 mutation carriers. Breast Cancer Linkage Consortium. Lancet 1994;343:692–695 [PubMed]
4. Ford D, Easton DF, Stratton M, et al. Genetic heterogeneity and penetrance analysis of the BRCA1 and BRCA2 genes in breast cancer families. Am J Hum Genet 1998;62:676–689 [PMC free article] [PubMed]
5. Brekelmans CT, Seynaeve C, Bartels CC, et al. Effectiveness of breast cancer surveillance in BRCA 1/2 gene mutation carriers and women with high familial risk. J Clin Oncol 2001;19:924–930 [PubMed]
6. Komenaka IK, Ditkoff B, Joseph K, et al. The development of interval breast malignancies in patients with BRCA mutations. Cancer 2004;100:2079–2083 [PubMed]
7. Scheuer L, Kauff N, Robson M, et al. Outcome of preventive surgery and screening for breast and ovarian cancer in BRCA mutation carriers. J Clin Oncol 2002;20:1260–1268 [PubMed]
8. Hamilton LJ, Evans AJ, Wilson AR, et al. Breast imaging findings in women with BRCA1- and BRCA2-associated breast carcinoma. Clin Radiol 2004;59:895–902 [PubMed]
9. Kaas R, Kroger R, Hendriks JHCL, et al. The significance of circumscribed malignant mammographic masses in the surveillance of BRCA 1/2 gene mutation carriers. Eur Radiol 2004;14:1647–1653 [PubMed]
10. Schrading S, Kuhl CK. Mammographic, US, and MR imaging phenotypes of familial breast cancer. Radiology 2008;246:58–70 [PubMed]
11. Tilanus-Linthorst M, Verhoog L, Obdeijn IM, et al. A BRCA 1/2 mutation, high breast density and prominent pushing margins of a tumor independently contribute to a frequent false-negative mammography. Int J Cancer 2002;102:91–95 [PubMed]
12. Pathology of familial breast cancer: differences between breast cancers in carriers of BRCA1 or BRCA2 mutations and sporadic cases. Breast Cancer Linkage Consortium. Lancet 1997;349:1505–1510 [PubMed]
13. Leach MO, Boggis CR, Dixon AK, et al. Screening with magnetic resonance imaging and mammography of a UK population at high familial risk of breast cancer: a prospective multicentre cohort study (MARIBS). Lancet 2005;365:1769–1778 [PubMed]
14. Kriege M, Brekelmans CT, Boetes C, et al. Efficacy of MRI and mammography for breast cancer screening in women with a familial or genetic predisposition. N Engl J Med 2004;351:427–437 [PubMed]
15. Warner E, Plewes DB, Hill KA, et al. Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. JAMA 2004;292:1317–1325 [PubMed]
16. Warner E, Plewes DB, Shumak RS, et al. Comparison of breast magnetic resonance imaging, mammography, and ultrasound for surveillance of women at high risk for hereditary breast cancer. J Clin Oncol 2001;19:3524–3531 [PubMed]
17. Kuhl CK, Schrading S, Leutner CC, et al. Mammography, breast ultrasound, and magnetic resonance imaging for surveillance of women at high familial risk for breast cancer. J Clin Oncol 2005;23:8469–8476 [PubMed]
18. Stoutjesdijk MJ, Boetes C, Jager GJ, et al. Magnetic resonance imaging and mammography in women with a hereditary risk of breast cancer. J Natl Cancer Inst 2001;93:1095–1102 [PubMed]
19. Tilanus-Linthorst MM, Obdeijn IM, Bartels KC, de Koning HJ, Oudkerk M. First experiences in screening women at high risk for breast cancer with MR imaging. Breast Cancer Res Treat 2000;63:53–60 [PubMed]
20. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007;57:75–89 [PubMed]
21. Panel on Cost-Effectiveness in Health and Medicine Cost-effectiveness in health and medicine New York, NY: Oxford University Press, 1996
22. Lee JM, Kopans DB, McMahon PM, et al. Breast cancer screening in BRCA1 mutation carriers: effectiveness of MR imaging—Markov Monte Carlo decision analysis. Radiology 2008;246:763–771 [PubMed]
23. Burke W, Daly M, Garber J, et al. Recommendations for follow-up care of individuals with an inherited predisposition to cancer. II. BRCA1 and BRCA2. JAMA 1997;277:997–1003 [PubMed]
24. Daly MB, Axilbund JE, Bryant E, et al. NCCN clinical practice guidelines in oncology: genetic/familial high-risk assessment—breast and ovarian Fort Washington, Pa: National Comprehensive Cancer Network, 2009
25. Breast Cancer Surveillance Consortium (BCSC) Frequency of node-positivity and metastatic cancer by primary tumor size and method of detection, 2005. http://breastscreening.cancer.gov/. Deidentified data obtained directly from BCSC.
26. Centers for Medicare and Medicaid Services Medicare physician fee schedule, 2007. http://www.cms.hhs.gov/PFSlookup/. Accessed February 5, 2009.
27. Surveillance Epidemiology and End Results (SEER) Program Public-use data, 1973-2001. National Cancer Institute. http://seer.cancer.gov/. Accessed February 5, 2009.
28. Kong CY, McMahon PM, Gazelle GS. Calibration of disease simulation model using an engineering approach. Value Health 2009;12:521–529 [PMC free article] [PubMed]
29. United States Bureau of Labor Statistics Consumer price index. http://www.data.bls.gov/cgi-bin/surveymost?cu. Accessed February 5, 2009
30. Peters NH, Borel Rinkes IH, Zuithoff NP, Mali WP, Moons KG, Peeters PH. Meta-analysis of MR imaging in the diagnosis of breast lesions. Radiology 2007;246:116–124 [PubMed]
31. Kriege M, Brekelmans CT, Boetes C, et al. Differences between first and subsequent rounds of the MRISC breast cancer screening program for women with a familial or genetic predisposition. Cancer 2006;106:2318–2326 [PubMed]
32. Kauff ND, Satagopan JM, Robson ME, et al. Risk-reducing salpingo-oophorectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med 2002;346:1609–1615 [PubMed]
33. Rebbeck TR, Lynch HT, Neuhausen SL, et al. Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations. N Engl J Med 2002;346:1616–1622 [PubMed]
34. Mandelblatt JS, Wheat ME, Monane M, Moshief RD, Hollenberg JP, Tang J. Breast cancer screening for elderly women with and without comorbid conditions. Ann Intern Med 1992;116:722–730 [PubMed]
35. Plevritis SK, Kurian AW, Sigal BM, et al. Cost-effectiveness of screening BRCA 1/2 mutation carriers with breast magnetic resonance imaging. JAMA 2006;295:2374–2384 [PubMed]
36. Stout NK, Rosenberg MA, Trentham-Dietz A, Smith MA, Robinson SM, Fryback DG. Retrospective cost-effectiveness analysis of screening mammography. J Natl Cancer Inst 2006;98:774–782 [PubMed]
37. Swan JS, Lawrence WF, Roy J. Process utility in breast biopsy. Med Decis Making 2006;26:347–359 [PubMed]
38. Schwartz LM, Woloshin S, Sox HC, Fischhoff B, Welch HG. US women’s attitudes to false positive mammography results and detection of ductal carcinoma in situ: cross sectional survey. BMJ 2000;320:1635–1640 [PMC free article] [PubMed]
39. Hirth RA, Chernew ME, Miller E, Fendrick AM, Weissert WG. Willingness to pay for a quality-adjusted life year: in search of a standard. Med Decis Making 2000;20:332–342 [PubMed]
40. Winkelmayer WC, Weinstein MC, Mittleman MA, Glynn RJ, Pliskin JS. Health economic evaluations: the special case of end-stage renal disease treatment. Med Decis Making 2002;22:417–430 [PubMed]
41. Salzmann P, Kerlikowske K, Phillips K. Cost-effectiveness of extending screening mammography guidelines to include women 40–49 years of age. Ann Intern Med 1997;127:955–965 [PubMed]
42. Kerlikowske K, Salzmann P, Phillips KA, Cauley JA, Cummings SR. Continuing screening mammography in women aged 70 to 79 years: impact on life expectancy and cost-effectiveness. JAMA 1999;282:2156–2163 [PubMed]
43. Early Breast Cancer Trialists’ Cooperative Group (EBCTCG) Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;365:1687–1717 [PubMed]
44. Schwartz GF, Hughes KS, Lynch HT, et al. Proceedings of the international consensus conference on breast cancer risk, genetics, & risk management, April 2007. Cancer 2008;113:2627–2637 [PubMed]

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