Highlights
- •A cost-effectiveness model compared RRSO+/−hysterectomy for BRCA1 mutation carriers.
- •RRSO + immediate hysterectomy is more effective and less costly than RRSO.
- •Delayed risk-reducing hysterectomy is cost-effective for up to 25 years after RRSO.
Abstract
Objective
To estimate the survival benefit and cost-effectiveness of performing hysterectomy
during risk-reducing salpingo-oophorectomy (RRSO) for BRCA1 mutation carriers.
Methods
Based on a recent prospective cohort study indicating an elevated incidence of serous/serous-like
uterine cancers among BRCA1 mutation carriers, we constructed a modified Markov decision model from a payer perspective
to inform decisions about performance of hysterectomy during RRSO at age 40. We assumed
patients had previously undergone a risk-reducing mastectomy and had a residual risk
of death from breast or ovarian cancer. Disease-specific survival, age-adjusted competing
hysterectomy rates, and deaths from other causes were incorporated. Costs of risk-reducing
surgery, competing hysterectomy, and care for serous/serous-like uterine cancer were
included.
Results
A 40 year old woman who undergoes RRSO + Hysterectomy gains 4.9 additional months of overall survival (40.38 versus 39.97 undiscounted
years) compared to RRSO alone. The lifetime probabilities of developing or dying from
serous/serous-like uterine cancer in the RRSO group are 3.5% and 2%, respectively.
The RRSO alone strategy has an average cost of $9013 compared to $8803 for RRSO + Hysterectomy, and is dominated (less effective and more costly) when compared to RRSO + Hysterectomy. In an alternative analysis, delayed hysterectomy remains a cost-effective
prevention strategy with an ICER of less than $100,000/year for up to 25 years following RRSO at age 40.
Conclusions
The addition of hysterectomy to RRSO in a 40 year old BRCA1 mutation carrier results in a mean gain of 4.9 additional months of life and is cost-effective.
Keywords
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References
- Gynecol. Oncol. 2005; 98: 179-181
- Hereditary breast and ovarian cancer syndrome.Gynecol. Oncol. 2009; 113: 6-11
- Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study.Lancet. 2007; 370: 1494-1499
- Pelvic organ prolapse.Lancet. 2007; 369: 1027-1038
- Is uterine papillary serous adenocarcinoma a manifestation of the hereditary breast-ovarian cancer syndrome?.Gynecol. Oncol. 2000; 79: 477-481
- Risk of endometrial carcinoma associated with BRCA mutation.Gynecol. Oncol. 2001; 80: 395-398
- BRCA1/2 germline mutations in Jewish patients with uterine serous carcinoma.Int. J. Gynecol. Cancer. 2010; 20: 1148-1153
- BRCA germline mutations in women with uterine serous carcinoma—still a debate.Int. J. Gynecol. Cancer. 2010; 20: 1531-1534
- Uterine cancer after risk-reducing salpingo-oophorectomy without hysterectomy in women with BRCA mutations.JAMA Oncol. 2016; 2: 1434-1440
- Survival analysis of cancer risk reduction strategies for BRCA1/2 mutation carriers.J. Clin. Oncol. 2010; 28 (Epub 2009/12/10): 222-231
Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Incidence - SEER 9 Regs Research Data, Nov 2015 Sub (1973–2013) <Katrina/Rita Population Adjustment> − Linked To County Attributes - Total U.S., 1969–2014 Counties, National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, (released April 2016, based on the November 2015 submission).
- How much is another randomized trial of lymph node dissection in endometrial cancer worth? A value of information analysis.Gynecol. Oncol. 2013; 131 (Epub 2013/06/27): 140-146
- United States life tables, 2011.Natl. Vital Stat. Rep. 2015; 64: 1-63
- Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine.JAMA. 2016; 316: 1093-1103
- Decreasing utilization of hysterectomy: a population-based study in Olmsted County, Minnesota, 1965–2002.Am. J. Obstet. Gynecol. 2007; 196 (214 e1–214 e7)
- Comparative effectiveness of robotically assisted compared with laparoscopic adnexal surgery for benign gynecologic disease.Obstet. Gynecol. 2014; 124: 886-896
- Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer.J. Clin. Oncol. 2012; 30 (Epub 2012/02/01): 783-791
- Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease.JAMA. 2013; 309: 689-698
- Surgical approach to hysterectomy for benign gynaecological disease.Cochrane Database Syst. Rev. 2015; 8CD003677
- Cost comparison among robotic, laparoscopic, and open hysterectomy for endometrial cancer.Obstet. Gynecol. 2010; 116 (Epub 2010/08/25): 685-693
- Costs and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies.JSLS. 2012; 16: 519-524
- Cost of care for elderly cancer patients in the United States.J. Natl. Cancer Inst. 2008; 100 (Epub 2008/05/01): 630-641
- Tom's Inflation Calculator.([cited 2016 8/15/16]; Available from:)
- Healthcare Cost and Utilization Project (HCUP).2012
- The impact of prophylactic salpingo-oophorectomy on menopausal symptoms and sexual function in women who carry a BRCA mutation.Gynecol. Oncol. 2011; 121: 163-168
- Prevalence of sexual dysfunction after risk-reducing salpingo-oophorectomy.Gynecol. Oncol. 2016; 140: 95-100
- Contributions of hysterectomy and uterus-preserving surgery to health-related quality of life.Obstet. Gynecol. 2013; 122: 15-25
- Quality of life and pelvic floor dysfunction symptoms after hysterectomy with or without pelvic organ prolapse.Eur. J. Obstet. Gynecol. Reprod. Biol. 2014; 182: 16-21
- Cost-effectiveness analysis of prevention strategies for gynecologic cancers in lynch syndrome.Cancer. 2008; 113: 326-335
Article info
Publication history
Published online: April 06, 2017
Accepted:
March 29,
2017
Received in revised form:
March 28,
2017
Received:
March 7,
2017
Identification
Copyright
© 2017 Elsevier Inc. All rights reserved.
