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Cost Effectiveness Analysis Of Universal Germline Testing For Pancreatic Cancer Patients
*Ashley N Krepline, *Jennifer Geurts, *Kristin Sanden, *Ben George, *Beth A Erickson, *William A Hall, *Srivats Madhavan, *Michael O Griffin, *Mandana Kamgar, Douglas B Evans, Susan Tsai, *Rebecca Y Kim
Medical College of Wisconsin, Milwaukee, WI

OBJECTIVE(S): Until recently, germline genetic testing for patients with pancreatic cancer (PC) has been selectively performed in individuals with a positive family history of cancer. Most recent NCCN guidelines now recommend universal germline testing for all patients with PC regardless of family history. Identifying pathogenic variants allows for cascade testing of family members who may also be at risk. Moreover, in a small portion of patients with PC, actionable variants will be identified which may alter therapeutic plans. Cost-effectiveness analysis of universal germline testing is needed.
METHODS: We conducted a cost-effectiveness analysis comparing universal versus selective germline testing for patients with PC using a decision-tree model. Cost estimates were determined based on 2019 institutional charges for genetic counseling ($248 USD) and commercially available multi-gene germline testing ($200 USD). We estimated probabilities based on published and institutional clinical data. Model outcomes included cost and cost-effectiveness where the benefit is defined as the identification of patients with an actionable pathogenic variant. We report the incremental cost-effectiveness ratio (ICER) as the incremental cost per unit of benefit. One-way sensitivity analyses were performed to test the robustness of the model.
RESULTS: Universal testing of a hypothetical cohort of 100 patients newly diagnosed with cancer would cost $41,900 USD and identify 7 patients with an actionable variant. In contrast, selective testing of a similar cohort would cost $12,900 USD and identify only 4 patients. ICER was $11,477USD per patient identified. Sensitivity analysis found that the probability of having a positive test result impacted the model results the most, increasing the ICER to $49,696 per unit benefit.
CONCLUSIONS: Our model suggests that universal testing may be cost-effective. This is likely driven by the relatively low incremental cost of genetic testing and counseling. Further analysis is needed to assess the cost-effectiveness over a longer, multigenerational time horizon while taking into account the health-utility associated with carrying a high-risk germline genetic mutation for cancer.


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