Mortality reduction and cost-effectiveness of performing hysterectomy at the time of risk-reducing salpingo-oophorectomy for prophylaxis against serous/serous-like uterine cancers in BRCA1 mutation carriers

To estimate the survival benefit and cost-effectiveness of performing hysterectomy during risk-reducing salpingo-oophorectomy (RRSO) for BRCA1 mutation carriers. Based on a recent prospective cohort study indicating an elevated incidence of serous/serous-like uterine cancers among BRCA1 mutation car...

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Published in:Gynecologic oncology Vol. 145; no. 3; pp. 549 - 554
Main Authors: Havrilesky, Laura J., Moss, Haley A., Chino, Junzo, Myers, Evan R., Kauff, Noah D.
Format: Journal Article
Language:English
Published: United States Elsevier Inc 01.06.2017
Subjects:
Adult
Aged
BRCA1
Cost-Benefit Analysis
Cost-effectiveness
Cystadenocarcinoma, Serous - economics
Cystadenocarcinoma, Serous - genetics
Cystadenocarcinoma, Serous - mortality
Cystadenocarcinoma, Serous - prevention & control
Female
Genes, BRCA1
Germ-Line Mutation
Hematology, Oncology and Palliative Medicine
Humans
Hysterectomy
Hysterectomy - economics
Hysterectomy - methods
Markov Chains
Middle Aged
Models, Statistical
Obstetrics and Gynecology
Ovariectomy - economics
Ovariectomy - methods
Prophylactic Surgical Procedures - economics
Prophylactic Surgical Procedures - methods
Risk-reducing salpingo-oophorectomy
United States - epidemiology
Uterine Neoplasms - economics
Uterine Neoplasms - genetics
Uterine Neoplasms - mortality
Uterine Neoplasms - prevention & control
Risk-reducing salpingo-oophorectomy
Hysterectomy
BRCA1
Cost-effectiveness
ISSN:0090-8258, 1095-6859, 1095-6859
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Summary:To estimate the survival benefit and cost-effectiveness of performing hysterectomy during risk-reducing salpingo-oophorectomy (RRSO) for BRCA1 mutation carriers. 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. A 40year 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 25years following RRSO at age 40. The addition of hysterectomy to RRSO in a 40year old BRCA1 mutation carrier results in a mean gain of 4.9 additional months of life and is cost-effective. •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 25years after RRSO.
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ISSN:0090-8258
1095-6859
1095-6859
DOI:10.1016/j.ygyno.2017.03.025