ELSIcon2022 Paper: Using cost-utility analysis to evaluate the health equity impacts of population genetic screening for BRCA1/BRCA2

ELSIcon2022 • Paper • May 31, 2022

Kate Saylor

Predictive genetic screening in unaffected individuals is becoming more accessible, but its relevance for advancing health equity is debated. Many current efforts to pilot population screening are funded by government institutions with clear obligations to serve those most in need. To justify the continuation or expansion of these programs, policymakers need to understand the potential value of genetic screening as well as its equity effects. Cost-utility analysis focuses on the utilitarian ideal of maximizing total benefits, however, it also has the potential to inform questions about the distribution of benefits essential to non-utilitarian theories of allocation. Using a model of BRCA1/BRCA2 screening in White and Black sub-populations, I address efficiency, equality, and equity questions relevant to utilitarian, process egalitarian, outcomes egalitarian, and sufficientarian views. I compare three screening uptake scenarios: equal uptake; higher uptake in White women reflecting utilization disparities; and targeted screening for Black women only. I report that all three scenarios meet typical cost-effectiveness thresholds. Higher genetic testing uptake among White women is the most cost-effective strategy ($7,879/QALY gained) and averts the most premature deaths. All screening strategies decrease (but do not eliminate) per-person lifetime healthcare spending disparities related to breast and ovarian cancer prevention and treatment. Additionally, screening reduces disparities in quality-adjusted life expectancy, but only if screening probability is at least equal for Black women. Population BRCA1/BRCA2 screening, therefore, has the potential to improve health equity if programs ensure fair access to screening.