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Snowsill TM, Coelho H, Morrish NG, Briscoe S, Boddy K, Smith T, Crosbie EJ, Ryan NA, Lalloo F, Hulme CT. Gynaecological cancer surveillance for women with Lynch syndrome: systematic review and cost-effectiveness evaluation. Health Technol Assess 2024; 28:1-228. [PMID: 39246007 PMCID: PMC11403379 DOI: 10.3310/vbxx6307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024] Open
Abstract
Background Lynch syndrome is an inherited condition which leads to an increased risk of colorectal, endometrial and ovarian cancer. Risk-reducing surgery is generally recommended to manage the risk of gynaecological cancer once childbearing is completed. The value of gynaecological colonoscopic surveillance as an interim measure or instead of risk-reducing surgery is uncertain. We aimed to determine whether gynaecological surveillance was effective and cost-effective in Lynch syndrome. Methods We conducted systematic reviews of the effectiveness and cost-effectiveness of gynaecological cancer surveillance in Lynch syndrome, as well as a systematic review of health utility values relating to cancer and gynaecological risk reduction. Study identification included bibliographic database searching and citation chasing (searches updated 3 August 2021). Screening and assessment of eligibility for inclusion were conducted by independent researchers. Outcomes were prespecified and were informed by clinical experts and patient involvement. Data extraction and quality appraisal were conducted and results were synthesised narratively. We also developed a whole-disease economic model for Lynch syndrome using discrete event simulation methodology, including natural history components for colorectal, endometrial and ovarian cancer, and we used this model to conduct a cost-utility analysis of gynaecological risk management strategies, including surveillance, risk-reducing surgery and doing nothing. Results We found 30 studies in the review of clinical effectiveness, of which 20 were non-comparative (single-arm) studies. There were no high-quality studies providing precise outcome estimates at low risk of bias. There is some evidence that mortality rate is higher for surveillance than for risk-reducing surgery but mortality is also higher for no surveillance than for surveillance. Some asymptomatic cancers were detected through surveillance but some cancers were also missed. There was a wide range of pain experiences, including some individuals feeling no pain and some feeling severe pain. The use of pain relief (e.g. ibuprofen) was common, and some women underwent general anaesthetic for surveillance. Existing economic evaluations clearly found that risk-reducing surgery leads to the best lifetime health (measured using quality-adjusted life-years) and is cost-effective, while surveillance is not cost-effective in comparison. Our economic evaluation found that a strategy of surveillance alone or offering surveillance and risk-reducing surgery was cost-effective, except for path_PMS2 Lynch syndrome. Offering only risk-reducing surgery was less effective than offering surveillance with or without surgery. Limitations Firm conclusions about clinical effectiveness could not be reached because of the lack of high-quality research. We did not assume that women would immediately take up risk-reducing surgery if offered, and it is possible that risk-reducing surgery would be more effective and cost-effective if it was taken up when offered. Conclusions There is insufficient evidence to recommend for or against gynaecological cancer surveillance in Lynch syndrome on clinical grounds, but modelling suggests that surveillance could be cost-effective. Further research is needed but it must be rigorously designed and well reported to be of benefit. Study registration This study is registered as PROSPERO CRD42020171098. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR129713) and is published in full in Health Technology Assessment; Vol. 28, No. 41. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | - Helen Coelho
- Peninsula Technology Assessment Group, University of Exeter, Exeter, UK
| | - Nia G Morrish
- Health Economics Group, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Exeter Policy Research Programme Evidence Review Facility, University of Exeter, Exeter, UK
| | - Kate Boddy
- NIHR Collaborations for Leadership in Applied Health Research and Care South West Peninsula, University of Exeter, Exeter, UK
| | | | - Emma J Crosbie
- Division of Cancer Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Neil Aj Ryan
- The Academic Women's Health Unit, University of Bristol, Bristol, UK
- Department of Obstetrics and Gynaecology, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Fiona Lalloo
- Manchester Centre for Genomic Medicine, Manchester University Hospitals Foundation Trust, Manchester, UK
| | - Claire T Hulme
- Health Economics Group, University of Exeter, Exeter, UK
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Umemiya M, Horikawa N, Kanai A, Saeki A, Ida K, Makio S, Yoshida T, Tsuji M, Gou R, Tani H, Usui T, Kosaka K. Endometrial Cancer Diagnosed at an Early Stage during Lynch Syndrome Surveillance: A Case Report. Case Rep Oncol 2023; 16:634-639. [PMID: 37933313 PMCID: PMC10625814 DOI: 10.1159/000531837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/21/2023] [Indexed: 11/08/2023] Open
Abstract
Lynch syndrome is an autosomal dominant inherited disorder caused by a germline pathogenic variant in DNA mismatch repair genes, resulting in multi-organ cancer. Annual transvaginal ultrasonography and endometrial biopsy are recommended for endometrial cancer surveillance in patients with Lynch syndrome in several guidelines; however, evidence is limited. Here, we present the case of a 51-year-old woman with endometrial cancer who underwent robot-assisted laparoscopic simple hysterectomy at an early stage detected by Lynch syndrome surveillance. The patient was a 51-year-old gravida zero woman without any medical history or symptoms. Her sister suffered from bladder, breast, rectal, and endometrial cancer and was diagnosed with Lynch syndrome using a hereditary cancer panel test (VistaSeq®). During gynecologic surveillance, the patient's endometrial cytology was classified as Papanicolaou class III. Therefore, she underwent endometrial curettage with hysteroscopy and was diagnosed with atypical endometrial hyperplasia. Robot-assisted hysterectomy was performed with a final pathological diagnosis of endometrial cancer (endometrioid carcinoma, Grade 1), stage 1A. She has remained disease-free for more than 12 months. Owing to advances in genetic medicine, prophylactic and therapeutic surgeries for hereditary cancers are increasing. To achieve an early diagnosis and treatment of Lynch syndrome-associated cancers, the importance of Lynch syndrome surveillance should be more widely recognized.
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Affiliation(s)
- Maki Umemiya
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Naoki Horikawa
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Ami Kanai
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Ayaka Saeki
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Kohei Ida
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Satoru Makio
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Teruki Yoshida
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Mitsuru Tsuji
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Rei Gou
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Hirohiko Tani
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Takeshi Usui
- Department of Genetics, Shizuoka General Hospital, Shizuoka, Japan
- Shizuoka Graduate University of Public Health, Shizuoka, Japan
| | - Kenzo Kosaka
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
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Etchegary H, Pike A, Puddester R, Watkins K, Warren M, Francis V, Woods M, Green J, Savas S, Seal M, Gao Z, Avery S, Curtis F, McGrath J, MacDonald D, Burry TN, Dawson L. Cancer prevention in cancer predisposition syndromes: A protocol for testing the feasibility of building a hereditary cancer research registry and nurse navigator follow up model. PLoS One 2022; 17:e0279317. [PMID: 36548287 PMCID: PMC9778977 DOI: 10.1371/journal.pone.0279317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Monogenic, high penetrance syndromes, conferring an increased risk of malignancies in multiple organs, are important contributors to the hereditary burden of cancer. Early detection and risk reduction strategies in patients with a cancer predisposition syndrome can save their lives. However, despite evidence supporting the benefits of early detection and risk reduction strategies, most Canadian jurisdictions have not implemented programmatic follow up of these patients. In our study site in the province of Newfoundland and Labrador (NL), Canada, there is no centralized, provincial registry of high-risk individuals. There is no continuity or coordination of care providing cancer genetics expertise and no process to ensure that patients are referred to the appropriate specialists or risk management interventions. This paper describes a study protocol to test the feasibility of obtaining and analyzing patient risk management data, specifically patients affected by hereditary breast ovarian cancer syndrome (HBOC; BRCA 1 and BRCA 2 genes) and Lynch syndrome (LS; MLH1, MSH2, MSH6, and PMS2 genes). Through a retrospective cohort study, we will describe these patients' adherence to risk management guidelines and test its relationship to health outcomes, including cancer incidence and stage. Through a qualitative interviews, we will determine the priorities and preferences of patients with any inherited cancer mutation for a follow up navigation model of risk management. Study data will inform a subsequent funding application focused on creating and evaluating a research registry and follow up nurse navigation model. It is not currently known what proportion of cancer mutation carriers are receiving care according to guidelines. Data collected in this study will provide clinical uptake and health outcome information so gaps in care can be identified. Data will also provide patient preference information to inform ongoing and planned research with cancer mutation carriers.
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Affiliation(s)
- Holly Etchegary
- Clinical Epidemiology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
- * E-mail:
| | - April Pike
- Faculty of Nursing, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Rebecca Puddester
- Faculty of Nursing, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Kathy Watkins
- Centre for Nursing and Health Studies, Eastern Health, St. John’s, Newfoundland, Canada
| | - Mike Warren
- Patient Partner, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Vanessa Francis
- Patient Partner, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Michael Woods
- Division of Biomedical Sciences, Discipline of Oncology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Jane Green
- Division of Biomedical Sciences, Discipline of Oncology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Sevtap Savas
- Division of Biomedical Sciences, Discipline of Oncology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Melanie Seal
- Discipline of Oncology, Faculty of Medicine, Memorial University of Newfoundland, Cancer Care Program, Eastern Health, St. John’s, Newfoundland, Canada
| | - Zhiwei Gao
- Clinical Epidemiology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Susan Avery
- Family Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Fiona Curtis
- Provincial Medical Genetics Program, Eastern Health, St. John’s, Newfoundland, Canada
| | - Jerry McGrath
- Gastroenterology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Donald MacDonald
- Newfoundland and Labrador Centre for Health Information, St. John’s, Newfoundland, Canada
| | - T. Nadine Burry
- Clinical Epidemiology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Lesa Dawson
- Obstetrics and Gynecology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
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Cost-Effectiveness of Risk-Reducing Surgery for Breast and Ovarian Cancer Prevention: A Systematic Review. Cancers (Basel) 2022; 14:cancers14246117. [PMID: 36551605 PMCID: PMC9776851 DOI: 10.3390/cancers14246117] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/04/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Policymakers require robust cost-effectiveness evidence of risk-reducing-surgery (RRS) for decision making on resource allocation for breast cancer (BC)/ovarian cancer (OC)/endometrial cancer (EC) prevention. We aimed to summarise published data on the cost-effectiveness of risk-reducing mastectomy (RRM)/risk-reducing salpingo-oophorectomy (RRSO)/risk-reducing early salpingectomy and delayed oophorectomy (RRESDO) for BC/OC prevention in intermediate/high-risk populations; hysterectomy and bilateral salpingo-oophorectomy (BSO) in Lynch syndrome women; and opportunistic bilateral salpingectomy (OBS) for OC prevention in baseline-risk populations. Major databases were searched until December 2021 following a prospective protocol (PROSPERO-CRD42022338008). Data were qualitatively synthesised following a PICO framework. Twenty two studies were included, with a reporting quality varying from 53.6% to 82.1% of the items scored in the CHEERS checklist. The incremental cost-effectiveness ratio/incremental cost-utility ratio and cost thresholds were inflated and converted to US$2020, using the original currency consumer price index (CPI) and purchasing power parities (PPP), for comparison. Eight studies concluded that RRM and/or RRSO were cost-effective compared to surveillance/no surgery for BRCA1/2, while RRESDO was cost-effective compared to RRSO in one study. Three studies found that hysterectomy with BSO was cost-effective compared to surveillance in Lynch syndrome women. Two studies showed that RRSO was also cost-effective at ≥4%/≥5% lifetime OC risk for pre-/post-menopausal women, respectively. Seven studies demonstrated the cost-effectiveness of OBS at hysterectomy (n = 4), laparoscopic sterilisation (n = 4) or caesarean section (n = 2). This systematic review confirms that RRS is cost-effective, while the results are context-specific, given the diversity in the target populations, health systems and model assumptions, and sensitive to the disutility, age and uptake rates associated with RRS. Additionally, RRESDO/OBS were sensitive to the uncertainty concerning the effect sizes in terms of the OC-risk reduction and long-term health impact. Our findings are relevant for policymakers/service providers and the design of future research studies.
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Ghose A, Bolina A, Mahajan I, Raza SA, Clarke M, Pal A, Sanchez E, Rallis KS, Boussios S. Hereditary Ovarian Cancer: Towards a Cost-Effective Prevention Strategy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191912057. [PMID: 36231355 PMCID: PMC9565024 DOI: 10.3390/ijerph191912057] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 05/25/2023]
Abstract
Ovarian cancer (OC) is the most lethal gynaecological malignancy. The search for a widely affordable and accessible screening strategy to reduce mortality from OC is still ongoing. This coupled with the late-stage presentation and poor prognosis harbours significant health-economic implications. OC is also the most heritable of all cancers, with an estimated 25% of cases having a hereditary predisposition. Advancements in technology have detected multiple mutations, with the majority affecting the BRCA1 and/or BRCA2 genes. Women with BRCA mutations are at a significantly increased lifetime risk of developing OC, often presenting with a high-grade serous pathology, which is associated with higher mortality due to its aggressive characteristic. Therefore, a targeted, cost-effective approach to prevention is paramount to improve clinical outcomes and mortality. Current guidelines offer multiple preventive strategies for individuals with hereditary OC (HOC), including genetic counselling to identify the high-risk women and risk-reducing interventions (RRI), such as surgical management or chemoprophylaxis through contraceptive medications. Evidence for sporadic OC is abundant as compared to the existing dearth in the hereditary subgroup. Hence, our review article narrates an overview of HOC and explores the RRI developed over the years. It attempts to compare the cost effectiveness of these strategies with women of the general population in order to answer the crucial question: what is the most prudent clinically and economically effective strategy for prevention amongst high-risk women?
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Affiliation(s)
- Aruni Ghose
- Department of Medical Oncology, Barts Cancer Centre, St. Bartholomew’s Hospital, Barts Health NHS Trust, London E1 1BB, UK
- Department of Medical Oncology, Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust, London SG1 4AB, UK
- Department of Medical Oncology, Medway NHS Foundation Trust, Gillingham ME7 5NY, UK
| | - Anita Bolina
- Department of Medical Oncology, Clatterbridge Cancer Centre, Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool CH63 4JY, UK
| | - Ishika Mahajan
- Department of Medical Oncology, Apollo Cancer Centre, Chennai 600001, India
| | - Syed Ahmer Raza
- Department of Internal Medicine, St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Miranda Clarke
- Department of Internal Medicine, Royal London Hospital, Barts Health NHS Trust, London E1 1BB, UK
| | - Abhinanda Pal
- Department of Internal Medicine, IQ City Medical College and Narayana Hospital, Durgapur 713206, India
| | - Elisabet Sanchez
- Department of Medical Oncology, Medway NHS Foundation Trust, Gillingham ME7 5NY, UK
| | - Kathrine Sofia Rallis
- Cancer Research Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London E1 4NS, UK
| | - Stergios Boussios
- Department of Medical Oncology, Medway NHS Foundation Trust, Gillingham ME7 5NY, UK
- Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, King’s College London, London WC2R 2LS, UK
- AELIA Organization, 9th Km Thessaloniki—Thermi, 57001 Thessaloniki, Greece
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Carneiro VCG, Gifoni ACLVC, Mauro Rossi B, Andrade CEMDC, Lima FTD, Galvão HDCR, Casali da Rocha JC, Silva Barreto LSD, Ashton‐Prolla P, Guindalini RSC, Farias TPD, Andrade WP, Fernandes PHDS, Ribeiro R, Lopes A, Tsunoda AT, Azevedo BRB, Marins CAM, Oliveira Uchôa DNDA, Dos Santos EAS, Fernández Coimbra FJ, Dias Filho FA, Lopes FCDO, Fernandes FG, Ritt GF, Laporte GA, Guimaraes GC, Feitosa e Castro Neto H, dos Santos JC, de Carvalho Vilela JB, Meinhardt Junior JG, Cunha JRD, Medeiros Milhomem L, da Silva LM, Maciel LDF, Ramalho NM, Leite Nunes R, Guido de Araújo R, de Assunção Ehrhardt R, Delgado Bocanegra RE, Silva Junior TC, Oliveira VRD, Silva Surimã W, de Melo Melquiades M, Ribeiro HSDC, Oliveira AF. Cancer risk‐reducing surgery: Brazilian society of surgical oncology guideline part 1 (gynecology and breast). J Surg Oncol 2022; 126:10-19. [DOI: 10.1002/jso.26812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Vandré Cabral Gomes Carneiro
- Department of Surgey, Gynecology, Oncology Instituto de Medicina Integral Professor Fernando Figueira Recife Brazil
- Department of Pelvic Surgery, Hereditary Cancer Program Hospital de Câncer de Pernambuco Recife Brazil
- Department of Oncogenetic, Oncology Oncologia D'or Rio de Janeiro Brazil
| | | | - Benedito Mauro Rossi
- Department of Oncogenetic, Surgical Oncology Hospital Sírio Libanês São Paulo Brazil
| | | | - Fernanda Teresa de Lima
- Department of Oncogenetic Hospital Israelita Albert Einstein São Paulo Brazil
- Department of Oncogenetic UNIFESP‐EPM São Paulo Brazil
| | | | | | | | | | | | | | - Wesley Pereira Andrade
- Department of Surgery Hospital Beneficência Portuguesa São Paulo Brazil
- Department of Surgery Hospital Oswaldo Cruz São Paulo Brazil
- Department of Surgery Hospital Santa Catarina São Paulo Brazil
| | | | - Reitan Ribeiro
- Department of Surgical Oncology Hospital Erasto Gaertner Curitiba Brazil
| | - Andre Lopes
- Department of Surgical Oncology São Camilo Oncologia São Paulo Brazil
| | - Audrey Tieko Tsunoda
- Department of Surgical Oncology Hospital Erasto Gaertner Curitiba Brazil
- Department of Surgery Pontifícia Universidade Católica do Paraná Curitiba Brazil
| | - Bruno Roberto Braga Azevedo
- Department of Surgical Oncology Oncoclínicas Curitiba Brazil
- Department of Surgery Pilar Hospital Curitiba Brazil
| | - Carlos Augusto Martinez Marins
- Department of Head and Neck, Oncological Surgery INCA Rio de Janeiro Brazil
- Department of Surgery Hospital Federal dos Servidores do Estado Rio de Janeiro Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jorge Guardiola Meinhardt Junior
- Department of Surgery Santa Casa de Misericórdia de Porto Alegre Porto Alegre Brazil
- Department of Surgery Hospital Santa Rita Porto Alegre Brazil
| | | | | | - Luciana Mata da Silva
- Department of Pelvic Surgery, Hereditary Cancer Program Hospital de Câncer de Pernambuco Recife Brazil
| | | | - Nathalia Moreira Ramalho
- Department of Surgey, Gynecology, Oncology Instituto de Medicina Integral Professor Fernando Figueira Recife Brazil
- Department of Oncogenetic, Oncology Oncologia D'or Rio de Janeiro Brazil
| | - Rafael Leite Nunes
- Department of Surgery GNDI Notredame Intermédica—Hospital Salvalus São Paulo Brazil
| | - Rodrigo Guido de Araújo
- Department of Pelvic Surgery, Hereditary Cancer Program Hospital de Câncer de Pernambuco Recife Brazil
| | | | | | | | | | | | | | - Heber Salvador de Castro Ribeiro
- Department of Oncogenetic, Abdominal Surgery A. C. Camargo Cancer Center São Paulo Brazil
- SBCO 2021‐2023 BBSO presidente Rio de Janeiro Brazil
| | - Alexandre Ferreira Oliveira
- Department of Surgery Universidade Federal de Juiz de Fora Juiz de Fora Brazil
- SBCO 2019‐2021 BBSO presidente Rio de Janeiro Brazil
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Xu X, Desai VB, Schwartz PE, Gross CP, Lin H, Schymura MJ, Wright JD. Safety Warning about Laparoscopic Power Morcellation in Hysterectomy: A Cost-Effectiveness Analysis of National Impact. WOMEN'S HEALTH REPORTS 2022; 3:369-384. [PMID: 35415718 PMCID: PMC8994439 DOI: 10.1089/whr.2021.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/09/2022]
Abstract
Background: Following a 2014 safety warning (that laparoscopic power morcellation may increase tumor dissemination if patients have occult uterine cancer), hysterectomy practice shifted from laparoscopic to abdominal approach. This avoided morcellating occult cancer, but increased perioperative complications. To inform the national impact of this practice change, we examined the cost-effectiveness of hysterectomy practice in the postwarning period, in comparison to counterfactual hysterectomy practice had there been no morcellation warning. Materials and Methods: We constructed a decision tree model to simulate relevant outcomes over the lifetime of patients in the national population undergoing hysterectomy for presumed benign indications. The model accounted for both hysterectomy- and occult cancer-related outcomes. Probability-, cost-, and utility weight-related input parameters were derived from analysis of the State Inpatient Databases, State Ambulatory Surgery and Services Databases, data from the New York Statewide Planning and Research Cooperative System and New York State Cancer Registry, and published literature. Results: With an estimated national sample of 353,567 adult women, base case analysis showed that changes in hysterectomy practice after the morcellation warning led to a net gain of 867.15 quality-adjusted life years (QALYs), but an increase of $19.54 million in costs (incremental cost-effectiveness ratio = $22,537/QALY). In probabilistic sensitivity analysis, the practice changes were cost-effective in 54.0% of the simulations when evaluated at a threshold of $50,000/QALY, which increased to 70.9% when evaluated at a threshold of $200,000/QALY. Conclusion: Hysterectomy practice changes induced by the morcellation warning are expected to be cost-effective, but uncertainty in parameter values may affect the cost-effectiveness results.
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Affiliation(s)
- Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Vrunda B. Desai
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- CooperSurgical, Inc., Trumbull, Connecticut, USA
| | - Peter E. Schwartz
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Haiqun Lin
- Division of Nursing Science, Rutgers University School of Nursing, Newark, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Newark, New Jersey, USA
| | - Maria J. Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, New York, USA
| | - Jason D. Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
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8
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Alblas M, Peterse EFP, Du M, Zauber AG, Steyerberg EW, van Leeuwen N, Lansdorp-Vogelaar I. Cost-effectiveness of prophylactic hysterectomy in first-degree female relatives with Lynch syndrome of patients diagnosed with colorectal cancer in the United States: a microsimulation study. Cancer Med 2021; 10:6835-6844. [PMID: 34510779 PMCID: PMC8495276 DOI: 10.1002/cam4.4080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 04/15/2021] [Accepted: 05/28/2021] [Indexed: 12/16/2022] Open
Abstract
Background To evaluate the cost‐effectiveness of prophylactic hysterectomy (PH) in women with Lynch syndrome (LS). Methods We developed a microsimulation model incorporating the natural history for the development of hyperplasia with and without atypia into endometrial cancer (EC) based on the MISCAN‐framework. We simulated women identified as first‐degree relatives (FDR) with LS of colorectal cancer patients after universal testing for LS. We estimated costs and benefits of offering this cohort PH, accounting for reduced quality of life after PH and for having EC. Three minimum ages (30/35/40) and three maximum ages (70/75/80) were compared to no PH. Results In the absence of PH, the estimated number of EC cases was 300 per 1,000 women with LS. Total associated costs for treatment of EC were $5.9 million. Offering PH to FDRs aged 40–80 years was considered optimal. This strategy reduced the number of endometrial cancer cases to 5.4 (−98%), resulting in 516 quality‐adjusted life years (QALY) gained and increasing the costs (treatment of endometrial cancer and PH) to $15.0 million (+154%) per 1,000 women. PH from earlier ages was more costly and resulted in fewer QALYs, although this finding was sensitive to disutility for PH. Conclusions Offering PH to 40‐ to 80‐year‐old women with LS is expected to add 0.5 QALY per person at acceptable costs. Women may decide to have PH at a younger age, depending on their individual disutility for PH and premature menopause.
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Affiliation(s)
- Maaike Alblas
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Elisabeth F P Peterse
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Mengmeng Du
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Nikki van Leeuwen
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
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Ryan N, Snowsill T, McKenzie E, Monahan KJ, Nebgen D. Should women with Lynch syndrome be offered gynaecological cancer surveillance? BMJ 2021; 374:n2020. [PMID: 34475027 DOI: 10.1136/bmj.n2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Naj Ryan
- The Academic Women's Health Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Obstetrics and Gynaecology, St Michael's Hospital, Bristol, UK
| | - T Snowsill
- Health Economics Group, University of Exeter Medical School, University of Exeter, Exeter, Devon, UK
| | | | - K J Monahan
- The Lynch Syndrome and Family Cancer Clinic, St Mark's Hospital and Academic Institute, Harrow, London, UK Imperial College London, London, UK
| | - D Nebgen
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Wright JD, Silver ER, Tan SX, Hur C, Kastrinos F. Cost-effectiveness Analysis of Genotype-Specific Surveillance and Preventive Strategies for Gynecologic Cancers Among Women With Lynch Syndrome. JAMA Netw Open 2021; 4:e2123616. [PMID: 34499134 PMCID: PMC8430458 DOI: 10.1001/jamanetworkopen.2021.23616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE With the expansion of multigene testing for cancer susceptibility, Lynch syndrome (LS) has become more readily identified among women. The condition is caused by germline pathogenic variants in DNA mismatch repair genes (ie, MLH1, MSH2, MSH6, and PMS2) and is associated with high but variable risks of endometrial and ovarian cancers based on genotype. However, current guidelines on preventive strategies are not specific to genotypes. OBJECTIVE To assess the cost-effectiveness of genotype-specific surveillance and preventive strategies for LS-associated gynecologic cancers, including a novel, risk-reducing surgical approach associated with decreased early surgically induced menopause. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation developed a cohort-level Markov simulation model of the natural history of LS-associated gynecologic cancer for each gene, among women from ages 25 to 75 years or until death from a health care perspective. Age was varied at hysterectomy and bilateral salpingo-oophorectomy (hyst-BSO) and at surveillance initiation, and a 2-stage surgical approach (ie, hysterectomy and salpingectomy at age 40 years and delayed oophorectomy at age 50 years [hyst-BS]) was included. Extensive 1-way and probabilistic sensitivity analyses were performed. INTERVENTIONS Hyst-BSO at ages 35 years, 40 years, or 50 years with or without annual surveillance beginning at age 30 years or 35 years or hyst-BS at age 40 years with oophorectomy delayed until age 50 years. MAIN OUTCOMES AND MEASURES Incremental cost-effectiveness ratio (ICER) between management strategies within an efficiency frontier. RESULTS For women with MLH1 and MSH6 variants, the optimal strategy was the 2-stage approach, with respective ICERs of $33 269 and $20 008 compared with hyst-BSO at age 40 years. Despite being cost-effective, the 2-stage approach was associated with increased cancer incidence and mortality compared with hyst-BSO at age 40 years for individuals with MLH1 variants (incidence: 7.76% vs 3.84%; mortality: 5.74% vs 2.55%) and those with MSH6 variants (incidence: 7.24% vs 4.52%; mortality: 5.22% vs 2.97%). Hyst-BSO at age 40 years was optimal for individuals with MSH2 variants, with an ICER of $5180 compared with hyst-BSO at age 35 years, and was associated with 4.42% cancer incidence and 2.97% cancer mortality. For individuals with PMS2 variants, hyst-BSO at age 50 years was optimal and all other strategies were dominated; hyst-BSO at age 50 years was associated with an estimated cancer incidence of 0.68% and cancer mortality of 0.29%. CONCLUSIONS AND RELEVANCE These findings suggest that gene-specific preventive strategies for gynecologic cancers in LS may be warranted and support hyst-BSO at age 40 years for individuals with MSH2 variants. For individuals with MLH1 and MSH6 variants, these findings suggest that a novel 2-stage surgical approach with delayed oophorectomy may be an alternative to hyst-BSO at age 40 years to avoid early menopause, and for individuals with PMS2 variants, the findings suggest that hyst-BSO may be delayed until age 50 years.
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Affiliation(s)
- Jason D. Wright
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- NewYork-Presbyterian Hospital, New York, New York
| | - Elisabeth R. Silver
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Sarah Xinhui Tan
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Chin Hur
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
- NewYork-Presbyterian Hospital, New York, New York
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Fay Kastrinos
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
- NewYork-Presbyterian Hospital, New York, New York
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2020 for the Clinical Practice of Hereditary Colorectal Cancer. Int J Clin Oncol 2021; 26:1353-1419. [PMID: 34185173 PMCID: PMC8286959 DOI: 10.1007/s10147-021-01881-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/10/2021] [Indexed: 12/14/2022]
Abstract
Hereditary colorectal cancer (HCRC) accounts for < 5% of all colorectal cancer cases. Some of the unique characteristics commonly encountered in HCRC cases include early age of onset, synchronous/metachronous cancer occurrence, and multiple cancers in other organs. These characteristics necessitate different management approaches, including diagnosis, treatment or surveillance, from sporadic colorectal cancer management. There are two representative HCRC, named familial adenomatous polyposis and Lynch syndrome. Other than these two HCRC syndromes, related disorders have also been reported. Several guidelines for hereditary disorders have already been published worldwide. In Japan, the first guideline for HCRC was prepared by the Japanese Society for Cancer of the Colon and Rectum (JSCCR), published in 2012 and revised in 2016. This revised version of the guideline was immediately translated into English and published in 2017. Since then, several new findings and novel disease concepts related to HCRC have been discovered. The currently diagnosed HCRC rate in daily clinical practice is relatively low; however, this is predicted to increase in the era of cancer genomic medicine, with the advancement of cancer multi-gene panel testing or whole genome testing, among others. Under these circumstances, the JSCCR guidelines 2020 for HCRC were prepared by consensus among members of the JSCCR HCRC Guideline Committee, based on a careful review of the evidence retrieved from literature searches, and considering the medical health insurance system and actual clinical practice settings in Japan. Herein, we present the English version of the JSCCR guidelines 2020 for HCRC.
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Gynecological Surveillance and Surgery Outcomes in Dutch Lynch Syndrome Carriers. Cancers (Basel) 2021; 13:cancers13030459. [PMID: 33530354 PMCID: PMC7865882 DOI: 10.3390/cancers13030459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Female Lynch syndrome (LS) carriers have an increased risk to develop endometrial and ovarian cancer. In the Netherlands, carriers are therefore advised annual gynecological surveillance and eventually, risk-reducing surgery. Global gynecological LS surveillance guidelines are scarce and based on limited evidence. These are, however, warranted to offer accurate surveillance. To provide more insight into surveillance outcomes, this study assessed outcomes of gynecological surveillance and risk-reducing surgery in 164 LS carriers diagnosed in our center, with a median follow-up of 5.6 years per carrier. Although most surveillance visits happened within an advised timeframe, we observed large variability in how gynecological surveillance visits were performed. This finding stresses the need for development of clear and evidence-based guidelines. Endometrial cancers identified at surveillance were all found in early stage, mostly symptomatic, questioning surveillance benefit. Large, prospective studies should assess to what extent current LS surveillance programs contribute to early detection of gynecological tumors. Abstract Lynch syndrome (LS) is caused by pathogenic germline variants in DNA mismatch repair (MMR) genes, predisposing female carriers for endometrial cancer (EC) and ovarian cancer (OC). Since gynecological LS surveillance guidelines are based on little evidence, we assessed its outcomes. Data regarding gynecological tumors, surveillance, and (risk-reducing) surgery were collected from female LS carriers diagnosed in our center since 1993. Of 505 female carriers, 104 had a gynecological malignancy prior to genetic LS diagnosis. Of 264 carriers eligible for gynecological management, 164 carriers gave informed consent and had available surveillance data: 38 MLH1, 25 MSH2, 82 MSH6, and 19 PMS2 carriers (median follow-up 5.6 years). Surveillance intervals were within advised time in >80%. Transvaginal ultrasound, endometrial sampling, and CA125 measurements were performed in 76.8%, 35.9%, and 40.6%, respectively. Four symptomatic ECs, one symptomatic OC, and one asymptomatic EC were diagnosed. Endometrial hyperplasia was found in eight carriers, of whom three were symptomatic. Risk-reducing surgery was performed in 73 (45.5%) carriers (median age 51 years), revealing two asymptomatic ECs. All ECs were diagnosed in FIGO I. Gynecological management in LS carriers varied largely, stressing the need for uniform, evidence-based guidelines. Most ECs presented early and symptomatically, questioning the surveillance benefit in its current form.
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Prophylactic Gynecologic Surgery at Time of Colectomy Benefits Women with Lynch Syndrome and Colon Cancer: A Markov Cost-Effectiveness Analysis. Dis Colon Rectum 2020; 63:1393-1402. [PMID: 32969882 DOI: 10.1097/dcr.0000000000001681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Women with Lynch syndrome who have completed childbearing should be offered prophylactic hysterectomy and bilateral salpingo-oophorectomy for gynecologic cancer prevention. The benefit of prophylactic gynecologic surgery at the time of colon cancer resection is unclear. OBJECTIVE This study aimed to compare the cost, quality of life, and likelihood of being alive and free from colon, endometrial, and ovarian cancer between operative choices for patients with Lynch syndrome undergoing surgery for colon cancer. DESIGN A Markov decision tree spanning 40 years was constructed for a hypothetical cohort of 30-year-old women with Lynch syndrome who had been diagnosed with colon cancer. Outcomes of 6 surgical strategies were compared, including segmental or total abdominal colectomy with or without hysterectomy alone or combined with bilateral salpingo-oophorectomy. SETTINGS A Markov cost-effectiveness analysis was performed at a single center. PATIENTS A literature search was performed identifying studies of patients with genetically diagnosed Lynch syndrome that described cost, risk of mortality, and quality of life after colon cancer resection and prophylactic gynecologic surgery. MAIN OUTCOME MEASURES The primary outcomes measured were quality-adjusted life-years and the likelihood of being alive and free from colon, endometrial, and ovarian cancer 40 years after surgery. RESULTS Women with Lynch syndrome who underwent a total abdominal colectomy and hysterectomy with bilateral salpingo-oophorectomy had the highest likelihood of being alive and cancer free. Total abdominal colectomy with hysterectomy was a close second, but yielded the largest amount of quality-adjusted life-years and lowest cost. LIMITATIONS This study is limited by the statistical method and quality of studies used. CONCLUSIONS Total abdominal colectomy with prophylactic hysterectomy at 30 years of age was the most cost-effective surgical choice in women with Lynch syndrome and colon cancer. The addition of bilateral salpingo-oophorectomy offered the highest event-free survival and lowest mortality. However, the additional morbidity of premature menopause of prophylactic salpingo-oophorectomy for younger women outweighed the benefit of ovarian cancer prevention. See Video Abstract at http://links.lww.com/DCR/B287. LA CIRUGÍA GINECOLÓGICA PROFILÁCTICA EN EL MOMENTO DE LA COLECTOMÍA BENEFICIA A LAS MUJERES CON SÍNDROME DE LYNCH Y CÁNCER DE COLON: UN ANÁLISIS DE COSTO-EFECTIVIDAD DE MARKOV: Las mujeres con síndrome de Lynch que han completado la maternidad deberían recibir histerectomía profiláctica y salpingooforectomía bilateral para la prevención del cáncer ginecológico. El beneficio de la cirugía ginecológica profiláctica en el momento de la resección del cáncer de colon no está claro.Comparar el costo, la calidad de vida y la probabilidad de estar viva y libre de cáncer de colon, endometrio y ovario entre las opciones quirúrgicas para pacientes con síndrome de Lynch sometidos a cirugía por cáncer de colon.Se construyó un árbol de decisión de Markov que abarca cuarenta años para una cohorte hipotética de mujeres de 30 años con síndrome de Lynch diagnosticadas con cáncer de colon. Se compararon los resultados de seis estrategias quirúrgicas, incluida la colectomía abdominal segmentaria o total con o sin histerectomía sola o combinada con salpingooforectomía bilateral.Se realizó un análisis de costo-efectividad de Markov en un solo centro.se realizó una búsqueda bibliográfica para identificar estudios de pacientes con síndrome de Lynch con diagnóstico genético que describieron el costo, el riesgo de mortalidad y la calidad de vida después de la resección del cáncer de colon y la cirugía ginecológica profiláctica.años de vida ajustados por calidad y probabilidad de estar vivo y libre de cáncer de colon, endometrio y ovario 40 años después de la cirugía.Las mujeres con síndrome de Lynch que se sometieron a una colectomía e histerectomía abdominal total con salpingooforectomía bilateral tuvieron la mayor probabilidad de estar vivas y libres de cáncer. La colectomía abdominal total con histerectomía fue un segundo lugar cercano, pero produjo la mayor cantidad de años de vida ajustados por calidad y el costo más bajo.Este estudio está limitado por el método estadístico y la calidad de los estudios utilizados.La colectomía abdominal total con histerectomía profiláctica a los 30 años fue la opción quirúrgica más rentable en mujeres con síndrome de Lynch y cáncer de colon. La adición de salpingooforectomía bilateral ofreció la mayor supervivencia libre de eventos y la menor mortalidad. Sin embargo, la morbilidad adicional de la menopausia prematura de la salpingooforectomía profiláctica para las mujeres más jóvenes superó el beneficio de la prevención del cáncer de ovario. Consulte Video Resumen en http://links.lww.com/DCR/B287. (Traducción-Dr. Yesenia Rojas-Khalil).
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14
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Cost-Effectiveness of Early Detection and Prevention Strategies for Endometrial Cancer-A Systematic Review. Cancers (Basel) 2020; 12:cancers12071874. [PMID: 32664613 PMCID: PMC7408795 DOI: 10.3390/cancers12071874] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/03/2020] [Accepted: 07/08/2020] [Indexed: 12/24/2022] Open
Abstract
Endometrial cancer is the most common female genital tract cancer in developed countries. We systematically reviewed the current health-economic evidence on early detection and prevention strategies for endometrial cancer based on a search in relevant databases (Medline/Embase/Cochrane Library/CRD/EconLit). Study characteristics and results including life-years gained (LYG), quality-adjusted life-years (QALY) gained, and incremental cost-effectiveness ratios (ICERs) were summarized in standardized evidence tables. Economic results were transformed into 2019 euros using standard conversion methods (GDP-PPP, CPI). Seven studies were included, evaluating (1) screening for endometrial cancer in women with different risk profiles, (2) risk-reducing interventions for women at increased or high risk for endometrial cancer, and (3) genetic testing for germline mutations followed by risk-reducing interventions for diagnosed mutation carriers. Compared to no screening, screening with transvaginal sonography (TVS), biomarker CA-125, and endometrial biopsy yielded an ICER of 43,600 EUR/LYG (95,800 EUR/QALY) in women with Lynch syndrome at high endometrial cancer risk. For women considering prophylactic surgery, surgery was more effective and less costly than screening. In obese women, prevention using Levonorgestrel as of age 30 for five years had an ICER of 72,000 EUR/LYG; the ICER for using oral contraceptives for five years as of age 50 was 450,000 EUR/LYG. Genetic testing for mutations in women at increased risk for carrying a mutation followed by risk-reducing surgery yielded ICERs below 40,000 EUR/QALY. Based on study results, preventive surgery in mutation carriers and genetic testing in women at increased risk for mutations are cost-effective. Except for high-risk women, screening using TVS and endometrial biopsy is not cost-effective and may lead to overtreatment. Model-based analyses indicate that future biomarker screening in women at increased risk for cancer may be cost-effective, dependent on high test accuracy and moderate test costs. Future research should reveal risk-adapted early detection and prevention strategies for endometrial cancer.
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15
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Sroczynski G, Gogollari A, Kuehne F, Hallsson LR, Widschwendter M, Pashayan N, Siebert U. A Systematic Review on Cost-effectiveness Studies Evaluating Ovarian Cancer Early Detection and Prevention Strategies. Cancer Prev Res (Phila) 2020; 13:429-442. [PMID: 32071120 DOI: 10.1158/1940-6207.capr-19-0506] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/01/2020] [Accepted: 02/14/2020] [Indexed: 11/16/2022]
Abstract
Ovarian cancer imposes a substantial health and economic burden. We systematically reviewed current health-economic evidence for ovarian cancer early detection or prevention strategies. Accordingly, we searched relevant databases for cost-effectiveness studies evaluating ovarian cancer early detection or prevention strategies. Study characteristics and results including quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICER) were summarized in standardized evidence tables. Economic results were transformed into 2017 Euros. The included studies (N = 33) evaluated ovarian cancer screening, risk-reducing interventions in women with heterogeneous cancer risks and genetic testing followed by risk-reducing interventions for mutation carriers. Multimodal screening with a risk-adjusted algorithm in postmenopausal women achieved ICERs of 9,800-81,400 Euros/QALY, depending on assumptions on mortality data extrapolation, costs, test performance, and screening frequency. Cost-effectiveness of risk-reducing surgery in mutation carriers ranged from cost-saving to 59,000 Euros/QALY. Genetic testing plus risk-reducing interventions for mutation carriers ranged from cost-saving to 54,000 Euros/QALY in women at increased mutation risk. Our findings suggest that preventive surgery and genetic testing plus preventive surgery in women at high risk for ovarian cancer can be considered effective and cost-effective. In postmenopausal women from the general population, multimodal screening using a risk-adjusted algorithm may be cost-effective.
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Affiliation(s)
- Gaby Sroczynski
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Artemisa Gogollari
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
- Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - Felicitas Kuehne
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Lára R Hallsson
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
- Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | | | - Nora Pashayan
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria.
- Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Kim JY, Byeon JS. Genetic Counseling and Surveillance Focused on Lynch Syndrome. JOURNAL OF THE ANUS RECTUM AND COLON 2019; 3:60-68. [PMID: 31559369 PMCID: PMC6752118 DOI: 10.23922/jarc.2019-002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 02/08/2019] [Indexed: 12/20/2022]
Abstract
Lynch syndrome is a hereditary cancer syndrome caused by germline mutations in one of several DNA mismatch repair genes. Lynch syndrome leads to an increased lifetime risk of various cancers, particularly colorectal, and endometrial cancers. After identifying patients suspected of having Lynch syndrome by clinical criteria, computational prediction models, and/or universal tumor testing, genetic testing is performed to confirm the diagnosis. Before and after genetic testing, genetic counseling should be provided. Genetic counseling should involve a detailed personal and family history, information on the disorder and genetic tests, discussion of the management and surveillance of the disease, career plan, family plan, and psychosocial support. Surveillance of colorectal cancer and other malignancies is of paramount importance for properly managing Lynch syndrome. This review focuses on important considerations in genetic counseling and the latest insights into the surveillance of individuals and families with Lynch syndrome.
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Affiliation(s)
- Jin Yong Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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17
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Endometrial Carcinoma, Grossing and Processing Issues: Recommendations of the International Society of Gynecologic Pathologists. Int J Gynecol Pathol 2019; 38 Suppl 1:S9-S24. [PMID: 30550481 PMCID: PMC6296844 DOI: 10.1097/pgp.0000000000000552] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Endometrial cancer is the most common gynecologic neoplasm in developed countries; however, updated universal guidelines are currently not available to handle specimens obtained during the surgical treatment of patients affected by this disease. This article presents recommendations on how to gross and submit sections for microscopic examination of hysterectomy specimens and other tissues removed during the surgical management of endometrial cancer such as salpingo-oophorectomy, omentectomy, and lymph node dissection—including sentinel lymph nodes. In addition, the intraoperative assessment of some of these specimens is addressed. These recommendations are based on a review of the literature, grossing manuals from various institutions, and a collaborative effort by a subgroup of the Endometrial Cancer Task Force of the International Society of Gynecological Pathologists. The aim of these recommendations is to standardize the processing of endometrial cancer specimens which is vital for adequate pathological reporting and will ultimately improve our understanding of this disease.
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18
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Staples JN, Duska LR. Cancer Screening and Prevention Highlights in Gynecologic Cancer. Obstet Gynecol Clin North Am 2019; 46:19-36. [DOI: 10.1016/j.ogc.2018.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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19
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Wong S, Ratner E, Buza N. Intra-operative evaluation of prophylactic hysterectomy and salpingo-oophorectomy specimens in hereditary gynaecological cancer syndromes. Histopathology 2018; 73:109-123. [DOI: 10.1111/his.13503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/21/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Serena Wong
- Department of Pathology; Yale University School of Medicine; New Haven CT USA
| | - Elena Ratner
- Department of Obstetrics and Gynecology; Division of Gynecologic Oncology; Yale University School of Medicine; New Haven CT USA
| | - Natalia Buza
- Department of Pathology; Yale University School of Medicine; New Haven CT USA
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Piszczek C, Ma J, Gould CH, Tseng P. Cancer Risk-Reducing Opportunities in Gynecologic Surgery. J Minim Invasive Gynecol 2017; 25:1179-1193. [PMID: 29097232 DOI: 10.1016/j.jmig.2017.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/20/2017] [Accepted: 10/21/2017] [Indexed: 12/16/2022]
Abstract
This review article discusses cancer risk-reducing opportunities in gynecologic surgery. We cover strategies to reduce ovarian and uterine cancer risk by presenting general practice guidelines and expanding on the literature behind clinical decision points. We address populations of women at increased hereditary risk and those at population risk. We specifically discuss risk-reducing salpingo-oophorectomy, prophylactic salpingectomy with delayed oophorectomy, concomitant hysterectomy, opportunistic salpingectomy, bilateral tubal ligation, and hysterectomy. For clinical scenarios in which data are limited or conflicting, we detail the studies on which clinicians' decisions hinge to allow the reader to weigh the available evidence.
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Affiliation(s)
- Carolyn Piszczek
- Division of Women's Services, Legacy Health System, Portland, Oregon.
| | - Jun Ma
- Divisions of Gynecologic Oncology, Legacy Medical Group, Portland, Oregon
| | - Claire H Gould
- Advanced Gynecology, Legacy Medical Group, Portland, Oregon
| | - Paul Tseng
- Divisions of Gynecologic Oncology, Legacy Medical Group, Portland, Oregon
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Bartosch C, Pires M, Jerónimo C, Lopes JM. The role of pathology in the management of patients with endometrial carcinoma. Future Oncol 2017; 13:1003-1020. [PMID: 28481146 DOI: 10.2217/fon-2016-0570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Pathology plays a critical role in every step in the management of endometrial carcinoma patients. In this review, we describe the state of the art of pathological examination, including examination of endometrium biopsy; intra-operative evaluation with gross examination and frozen section; and grossing of hysterectomy specimen and its histological and immunohistochemistry study. The main pathologic findings in each step are described, as well as limitations and difficulties that may ensue. We highlight the important pathologic parameters that determine treatment options and prognosis of endometrial cancer patients.
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Affiliation(s)
- Carla Bartosch
- Department of Pathology, Portuguese Oncology Institute of Porto, Porto, Portugal.,Department of Pathology and Oncology, Medical Faculty, University of Porto, Porto, Portugal.,Cancer Biology & Epigenetics Group, Research Center, Portuguese Oncology Institute of Porto, Porto, Portugal.,Porto Comprehensive Cancer Center (PCCC), Porto, Portugal
| | - Mónica Pires
- Porto Comprehensive Cancer Center (PCCC), Porto, Portugal.,Department of Gynecology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Carmen Jerónimo
- Cancer Biology & Epigenetics Group, Research Center, Portuguese Oncology Institute of Porto, Porto, Portugal.,Porto Comprehensive Cancer Center (PCCC), Porto, Portugal.,Department of Pathology & Molecular Immunology, Institute of Biomedical Sciences Abel Salazar-ICBAS, University of Porto, Porto, Portugal
| | - José Manuel Lopes
- Department of Pathology and Oncology, Medical Faculty, University of Porto, Porto, Portugal.,Department of Pathology, Centro Hospitalar de São João, Porto, Portugal.,IPATIMUP (Institute of Molecular Pathology & Immunology, University of Porto) & I3S - Instituto de Investigação e Inovação em Saúde, University of Porto, Portugal
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22
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Prince AER, Cadigan RJ, Henderson GE, Evans JP, Adams M, Coker-Schwimmer E, Penn DC, Van Riper M, Corbie-Smith G, Jonas DE. Is there evidence that we should screen the general population for Lynch syndrome with genetic testing? A systematic review. Pharmgenomics Pers Med 2017; 10:49-60. [PMID: 28260941 PMCID: PMC5325104 DOI: 10.2147/pgpm.s123808] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The emerging dual imperatives of personalized medicine and technologic advances make population screening for preventable conditions resulting from genetic alterations a realistic possibility. Lynch syndrome is a potential screening target due to its prevalence, penetrance, and the availability of well-established, preventive interventions. However, while population screening may lower incidence of preventable conditions, implementation without evidence may lead to unintentional harms. We examined the literature to determine whether evidence exists that screening for Lynch-associated mismatch repair (MMR) gene mutations leads to improved overall survival, cancer-specific survival, or quality of life. Documenting evidence and gaps is critical to implementing genomic approaches in public health and guiding future research. MATERIALS AND METHODS Our 2014-2015 systematic review identified studies comparing screening with no screening in the general population, and controlled studies assessing analytic validity of targeted next-generation sequencing, and benefits or harms of interventions or screening. We conducted meta-analyses for the association between early or more frequent colonoscopies and health outcomes. RESULTS Twelve studies met our eligibility criteria. No adequate evidence directly addressed the main question or the harms of screening in the general population. Meta-analyses found relative reductions of 68% for colorectal cancer incidence (relative risk: 0.32, 95% confidence interval: 0.23-0.43, three cohort studies, 590 participants) and 78% for all-cause mortality (relative risk: 0.22, 95% confidence interval: 0.09-0.56, three cohort studies, 590 participants) for early or more frequent colonoscopies among family members of people with cancer who also had an associated MMR gene mutation. CONCLUSION Inadequate evidence exists examining harms and benefits of population-based screening for Lynch syndrome. Lack of evidence highlights the need for data that directly compare benefits and harms.
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Affiliation(s)
| | - R Jean Cadigan
- Center for Genomics and Society
- Department of Social Medicine
| | | | - James P Evans
- Center for Genomics and Society
- Department of Genetics
- Carolina Center for Genome Sciences
- Lineberger Comprehensive Cancer Center
- Department of Medicine
| | - Michael Adams
- Center for Genomics and Society
- Department of Genetics
| | | | | | - Marcia Van Riper
- Center for Genomics and Society
- School of Nursing, The University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Giselle Corbie-Smith
- Center for Genomics and Society
- Department of Social Medicine
- Department of Medicine
| | - Daniel E Jonas
- Center for Genomics and Society
- Department of Medicine
- Cecil G. Sheps Center for Health Services Research
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Pathologic Findings in Prophylactic and Nonprophylactic Hysterectomy Specimens of Patients With Lynch Syndrome. Am J Surg Pathol 2016; 40:1177-91. [DOI: 10.1097/pas.0000000000000684] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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24
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Methods Used in Economic Evaluations of Testing and Diagnosis for Ovarian Cancer: A Systematic Review. Int J Gynecol Cancer 2016; 26:865-72. [PMID: 27051058 DOI: 10.1097/igc.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE There are multiple tests available that can help diagnose ovarian cancer, and the cost-effective analysis of these diagnostic interventions is essential for making well-informed decisions regarding resource allocation. There are multiple factors that can impact on the conclusions drawn from economic evaluations including test accuracy, the impact of the testing pathway on patient costs and outcomes, and delays along the ovarian cancer test-treat pathway. The objective of this study was to evaluate how test accuracy, the choice of perspective, and delays along the testing and diagnostic pathway have been incorporated in economic evaluations of testing for ovarian cancer. METHODS A systematic review of published literature was undertaken to identify economic evaluations (eg, cost-effectiveness, cost-utility analysis) focused on testing and diagnosis for ovarian cancer. RESULTS Seven studies met the inclusion criteria. Six studies incorporated test accuracy and its impact on patients to some extent. Four studies adopted a societal perspective, but only one considered the costs incurred by patients on the testing and diagnosis pathway. Where delays on the testing pathway were incorporated into the analysis, these were frequently due to false-negative test results leading to delays in patients accessing treatment. Any anxiety that patients might experience as a result of a positive test was not considered in these studies. CONCLUSIONS The impact on patients of receiving a positive test in terms of anxiety and the costs incurred by patients having to attend for testing and diagnosis are rarely considered. Delays along the testing and diagnosis pathway can have a major effect on patient outcomes, and it is important that these are acknowledged in economic evaluations focused on testing. Future economic analysis should incorporate these key determinants in order that diagnostic tests for ovarian cancer can be robustly evaluated.
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Abstract
Lynch syndrome (LS) is the most common of all inherited cancer syndromes, associated with substantially elevated risks for colonic and extracolonic malignancies, earlier onset and high rates of multiple primary cancers. At the genetic level, it is caused by a defective mismatch repair (MMR) system due to presence of germline defects in at least one of the MMR genes- MLH1, MSH2, MSH6, PMS2 or EPCAM. An impaired MMR function during replication introduces infidelity in DNA sequence and leads to ubiquitous mutations at simple repetitive sequences (microsatellites), causing microsatellite instability (MSI). Although previously, clinicopathological criteria such as Amsterdam I/II and Revised Bethesda Guidelines were commonly used to identify suspected LS mutation carriers, there has been a recent push towards universally testing, especially in case of colorectal cancers (CRCs), through immunohistochemistry for expression of MMR proteins or through molecular tests (polymerase chain reaction, PCR) for MSI, in order to identify LS mutation carriers and subject them to genetic testing to ascertain the specific gene implicated. In this review, we have discussed the latest diagnostic strategies and the current screening and treatment guidelines for colonic and extracolonic cancers in clinically affected and at-risk individuals for LS.
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Affiliation(s)
- A K Tiwari
- From the Section of Gastroenterology, Boston University Medical Center, Boston, MA, USA and
| | - H K Roy
- From the Section of Gastroenterology, Boston University Medical Center, Boston, MA, USA and
| | - H T Lynch
- Department of Preventive Medicine and Public Health, Creighton University, Omaha NE, USA
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26
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Wright JD, Cui RR, Wang A, Chen L, Tergas AI, Burke WM, Ananth CV, Hou JY, Neugut AI, Temkin SM, Wang YC, Hershman DL. Economic and Survival Implications of Use of Electric Power Morcellation for Hysterectomy for Presumed Benign Gynecologic Disease. J Natl Cancer Inst 2015; 107:djv251. [PMID: 26449386 PMCID: PMC4849362 DOI: 10.1093/jnci/djv251] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 03/19/2015] [Accepted: 08/06/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Electric power morcellation during laparoscopic hysterectomy allows some women to undergo minimally invasive surgery but may disrupt underlying occult malignancies and increase the risk of tumor dissemination. METHODS We developed a state transition Markov cohort simulation model of the risks and benefits of hysterectomy (abdominal, laparoscopic, and laparoscopic with electric power morcellation) for women with presumed benign gynecologic disease. The model considered perioperative morbidity, mortality, risk of cancer and dissemination, and outcomes in women with an underlying malignancy. We explored the effectiveness from a societal perspective stratified by age (<40, 40-49, 50-59, and ≥60 years). RESULTS Under all scenarios, modeled laparoscopic hysterectomy without morcellation was the most beneficial strategy. Laparoscopic hysterectomy with morcellation was associated with 80.83 more intraoperative complications, 199.64 fewer perioperative complications, and 241.80 fewer readmissions than abdominal hysterectomy per 10 000 women. Per 10 000 women younger than age 40 years, laparoscopic hysterectomy with morcellation was associated with 1.57 more cases of disseminated cancer and 0.97 fewer deaths than abdominal hysterectomy. The excess cases of disseminated cancer per 10 000 women with morcellation compared with abdominal hysterectomy increased with age to 47.54 per 10 000 in women age 60 years and older. Compared with abdominal hysterectomy, this resulted in 0.30 (age 40-49 years), 5.07 (age 50-59 years), and 18.14 (age 60 years and older) excess deaths per 10 000 women in the respective age groups. CONCLUSION Laparoscopic hysterectomy without morcellation is the most beneficial approach of the three methods of hysterectomy studied. In older women, the risks of electric power morcellation may outweigh the benefits of minimally invasive hysterectomy.
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Affiliation(s)
- Jason D Wright
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT).
| | - Rosa R Cui
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Anqi Wang
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Ling Chen
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Ana I Tergas
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - William M Burke
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Cande V Ananth
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - June Y Hou
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Alfred I Neugut
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Sarah M Temkin
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Y Claire Wang
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
| | - Dawn L Hershman
- : Department of Obstetrics and Gynecology (JDW, RRC, LC, AIT, WMB, CVA, JYH) and Department of Medicine (AIN, DLH), Columbia University College of Physicians and Surgeons; Department of Epidemiology (AIT, CVA, AIN, DLH) and Department of Health Policy and Management (AW, YCW), Mailman School of Public Health, Columbia University; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons (JDW, AIT, WMB, JYH, AIN, DLH); New York Presbyterian Hospital, New York, NY (JDW, AIT, WMB, JYH, AIN, DLH); National Cancer Institute, Bethesda, MD (SMT)
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27
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Grosse SD. When is Genomic Testing Cost-Effective? Testing for Lynch Syndrome in Patients with Newly-Diagnosed Colorectal Cancer and Their Relatives. Healthcare (Basel) 2015; 3:860-78. [PMID: 26473097 PMCID: PMC4604059 DOI: 10.3390/healthcare3040860] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Varying estimates of the cost-effectiveness of genomic testing applications can reflect differences in study questions, settings, methods and assumptions. This review compares recently published cost-effectiveness analyses of testing strategies for Lynch Syndrome (LS) in tumors from patients newly diagnosed with colorectal cancer (CRC) for either all adult patients or patients up to age 70 along with cascade testing of relatives of probands. Seven studies published from 2010 through 2015 were identified and summarized. Five studies analyzed the universal offer of testing to adult patients with CRC and two others analyzed testing patients up to age 70; all except one reported incremental cost-effectiveness ratios (ICERs) < $ 100,000 per life-year or quality-adjusted life-year gained. Three studies found lower ICERs for selective testing strategies using family history-based predictive models compared with universal testing. However, those calculations were based on estimates of sensitivity of predictive models derived from research studies, and it is unclear how sensitive such models are in routine clinical practice. Key model parameters that are influential in ICER estimates included 1) the number of first-degree relatives tested per proband identified with LS and 2) the cost of gene sequencing. Others include the frequency of intensive colonoscopic surveillance, the cost of colonoscopy, and the inclusion of extracolonic surveillance and prevention options.
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Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA; Tel.: +404-498-3074
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Management of Patients with Hereditary Colorectal Cancer Syndromes. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2015; 22:204-212. [PMID: 28868409 PMCID: PMC5580105 DOI: 10.1016/j.jpge.2015.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 06/13/2015] [Indexed: 12/16/2022]
Abstract
Colorectal cancer (CRC) is one of the most important causes of death in the world. Hereditary CRC is found in 5–10% of CRC patients. In this review, we will focus on the major forms of hereditary CRC and their management according to the most recent literature available.
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Snowsill T, Huxley N, Hoyle M, Jones-Hughes T, Coelho H, Cooper C, Frayling I, Hyde C. A systematic review and economic evaluation of diagnostic strategies for Lynch syndrome. Health Technol Assess 2015; 18:1-406. [PMID: 25244061 DOI: 10.3310/hta18580] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Lynch syndrome (LS) is an inherited autosomal dominant disorder characterised by an increased risk of colorectal cancer (CRC) and other cancers, and caused by mutations in the deoxyribonucleic acid (DNA) mismatch repair genes. OBJECTIVE To evaluate the accuracy and cost-effectiveness of strategies to identify LS in newly diagnosed early-onset CRC patients (aged < 50 years). Cascade testing of relatives is employed in all strategies for individuals in whom LS is identified. DATA SOURCES AND METHODS Systematic reviews were conducted of the test accuracy of microsatellite instability (MSI) testing or immunohistochemistry (IHC) in individuals with CRC at risk of LS, and of economic evidence relating to diagnostic strategies for LS. Reviews were carried out in April 2012 (test accuracy); and in February 2012, repeated in February 2013 (economic evaluations). Databases searched included MEDLINE (1946 to April week 3, 2012), EMBASE (1980 to week 17, 2012) and Web of Science (inception to 30 April 2012), and risk of bias for test accuracy was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) quality appraisal tool. A de novo economic model of diagnostic strategies for LS was developed. RESULTS Inconsistencies in study designs precluded pooling of diagnostic test accuracy results from a previous systematic review and nine subsequent primary studies. These were of mixed quality, with significant methodological concerns identified for most. IHC and MSI can both play a part in diagnosing LS but neither is gold standard. No UK studies evaluated the cost-effectiveness of diagnosing and managing LS, although studies from other countries generally found some strategies to be cost-effective compared with no testing. The de novo model demonstrated that all strategies were cost-effective compared with no testing at a threshold of £20,000 per quality-adjusted life-year (QALY), with the most cost-effective strategy utilising MSI and BRAF testing [incremental cost-effectiveness ratio (ICER) = £5491 per QALY]. The maximum health benefit to the population of interest would be obtained using universal germline testing, but this would not be a cost-effective use of NHS resources compared with the next best strategy. When the age limit was raised from 50 to 60 and 70 years, the ICERs compared with no testing increased but remained below £20,000 per QALY (except for universal germline testing with an age limit of 70 years). The total net health benefit increased with the age limit as more individuals with LS were identified. Uncertainty was evaluated through univariate sensitivity analyses, which suggested that the parameters substantially affecting cost-effectiveness: were the risk of CRC for individuals with LS; the average number of relatives identified per index patient; the effectiveness of colonoscopy in preventing metachronous CRC; the cost of colonoscopy; the duration of the psychological impact of genetic testing on health-related quality of life (HRQoL); and the impact of prophylactic hysterectomy and bilateral salpingo-oophorectomy on HRQoL (this had the potential to make all testing strategies more expensive and less effective than no testing). LIMITATIONS The absence of high-quality data for the impact of prophylactic gynaecological surgery and the psychological impact of genetic testing on HRQoL is an acknowledged limitation. CONCLUSIONS Results suggest that reflex testing for LS in newly diagnosed CRC patients aged < 50 years is cost-effective. Such testing may also be cost-effective in newly diagnosed CRC patients aged < 60 or < 70 years. Results are subject to uncertainty due to a number of parameters, for some of which good estimates were not identified. We recommend future research to estimate the cost-effectiveness of testing for LS in individuals with newly diagnosed endometrial or ovarian cancer, and the inclusion of aspirin chemoprevention. Further research is required to accurately estimate the impact of interventions on HRQoL. STUDY REGISTRATION This study is registered as PROSPERO CRD42012002436. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Martin Hoyle
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Ian Frayling
- Institute of Medical Genetics, Cardiff University, Cardiff, UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
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ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes. Am J Gastroenterol 2015; 110:223-62; quiz 263. [PMID: 25645574 PMCID: PMC4695986 DOI: 10.1038/ajg.2014.435] [Citation(s) in RCA: 1007] [Impact Index Per Article: 111.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 12/01/2014] [Indexed: 02/06/2023]
Abstract
This guideline presents recommendations for the management of patients with hereditary gastrointestinal cancer syndromes. The initial assessment is the collection of a family history of cancers and premalignant gastrointestinal conditions and should provide enough information to develop a preliminary determination of the risk of a familial predisposition to cancer. Age at diagnosis and lineage (maternal and/or paternal) should be documented for all diagnoses, especially in first- and second-degree relatives. When indicated, genetic testing for a germline mutation should be done on the most informative candidate(s) identified through the family history evaluation and/or tumor analysis to confirm a diagnosis and allow for predictive testing of at-risk relatives. Genetic testing should be conducted in the context of pre- and post-test genetic counseling to ensure the patient's informed decision making. Patients who meet clinical criteria for a syndrome as well as those with identified pathogenic germline mutations should receive appropriate surveillance measures in order to minimize their overall risk of developing syndrome-specific cancers. This guideline specifically discusses genetic testing and management of Lynch syndrome, familial adenomatous polyposis (FAP), attenuated familial adenomatous polyposis (AFAP), MUTYH-associated polyposis (MAP), Peutz-Jeghers syndrome, juvenile polyposis syndrome, Cowden syndrome, serrated (hyperplastic) polyposis syndrome, hereditary pancreatic cancer, and hereditary gastric cancer.
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Dębniak T, Gromowski T, Scott RJ, Gronwald J, Huzarski T, Byrski T, Kurzawski G, Dymerska D, Górski B, Paszkowska-Szczur K, Cybulski C, Serrano-Fernandez P, Lubiński J. Management of ovarian and endometrial cancers in women belonging to HNPCC carrier families: review of the literature and results of cancer risk assessment in Polish HNPCC families. Hered Cancer Clin Pract 2015; 13:3. [PMID: 25606063 PMCID: PMC4300044 DOI: 10.1186/s13053-015-0025-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 01/05/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Over half the cancer deaths in HNPCC families are due to extra-colonic malignancies that include endometrial and ovarian cancers. The benefits of surveillance for gynecological cancers are not yet proven and there is no consensus on the optimal surveillance recommendations for women with MMR mutations. METHODS We performed a systematic review of the literature and evaluated gynecological cancer risk in a series of 631 Polish HNPCC families classified into either Lynch Syndrome (LS, MMR mutations detected) or HNPCC (fulfillment of the Amsterdam or modified Amsterdam criteria). RESULTS Published data clearly indicates no benefit for ovarian cancer screening in contrast to risk reducing surgery. We confirmed a significantly increased risk of OC in Polish LS families (OR = 4,6, p < 0.001) and an especially high risk of OC was found for women under 50 years of age: OR = 32,6, p < 0.0001 (95% CI 12,96-81,87). The cumulative OC risk to 50 year of life was calculated to be 10%. Six out of 19 (32%) early-onset patients from LS families died from OC within 2 years of diagnosis. We confirmed a significantly increased risk of EC (OR = 26, 95% CI 11,36-58,8; p < 0,001). The cumulative risk for EC in Polish LS families was calculated to be 67%. CONCLUSIONS Due to the increased risk of OC and absence of any benefit from gynecological screening reported in the literature it is recommended that prophylactic oophorectomy for female carriers of MMR mutations after 35 year of age should be considered as a risk reducing option. Annual transvaginal ultrasound supported by CA125 or HE4 marker testing should be performed after prophylactic surgery in these women. Due to the high risk of EC it is reasonable to offer, after the age of 35 years, annual clinical gynecologic examinations with transvaginal ultrasound supported by routine aspiration sampling of the endometrium for women from either LS or HNPCC families. An alternative option, which could be taken into consideration for women preferring surgical prevention, is risk reducing total hysterectomy (with bilateral salpingo-oophorectomy) for carriers after childbearing is complete.
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Affiliation(s)
- Tadeusz Dębniak
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
| | - Tomasz Gromowski
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
| | - Rodney J Scott
- Discipline of Medical Genetics, Faculty of Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW Australia
| | - Jacek Gronwald
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
| | - Tomasz Huzarski
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
| | - Tomasz Byrski
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
| | - Grzegorz Kurzawski
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
| | - Dagmara Dymerska
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
| | - Bohdan Górski
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
| | - Katarzyna Paszkowska-Szczur
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
| | - Cezary Cybulski
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
| | - Pablo Serrano-Fernandez
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
| | - Jan Lubiński
- Department o f Genetics and Pathology, International Hereditary Cancer Center, Pomeranian Medical University, Szczecin, Poland
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Manchanda R, Legood R, Burnell M, McGuire A, Raikou M, Loggenberg K, Wardle J, Sanderson S, Gessler S, Side L, Balogun N, Desai R, Kumar A, Dorkins H, Wallis Y, Chapman C, Taylor R, Jacobs C, Tomlinson I, Beller U, Menon U, Jacobs I. Cost-effectiveness of population screening for BRCA mutations in Ashkenazi jewish women compared with family history-based testing. J Natl Cancer Inst 2015; 107:380. [PMID: 25435542 PMCID: PMC4301704 DOI: 10.1093/jnci/dju380] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 06/18/2014] [Accepted: 10/14/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Population-based testing for BRCA1/2 mutations detects the high proportion of carriers not identified by cancer family history (FH)-based testing. We compared the cost-effectiveness of population-based BRCA testing with the standard FH-based approach in Ashkenazi Jewish (AJ) women. METHODS A decision-analytic model was developed to compare lifetime costs and effects amongst AJ women in the UK of BRCA founder-mutation testing amongst: 1) all women in the population age 30 years or older and 2) just those with a strong FH (≥10% mutation risk). The model assumes that BRCA carriers are offered risk-reducing salpingo-oophorectomy and annual MRI/mammography screening or risk-reducing mastectomy. Model probabilities utilize the Genetic Cancer Prediction through Population Screening trial/published literature to estimate total costs, effects in terms of quality-adjusted life-years (QALYs), cancer incidence, incremental cost-effectiveness ratio (ICER), and population impact. Costs are reported at 2010 prices. Costs/outcomes were discounted at 3.5%. We used deterministic/probabilistic sensitivity analysis (PSA) to evaluate model uncertainty. RESULTS Compared with FH-based testing, population-screening saved 0.090 more life-years and 0.101 more QALYs resulting in 33 days' gain in life expectancy. Population screening was found to be cost saving with a baseline-discounted ICER of -£2079/QALY. Population-based screening lowered ovarian and breast cancer incidence by 0.34% and 0.62%. Assuming 71% testing uptake, this leads to 276 fewer ovarian and 508 fewer breast cancer cases. Overall, reduction in treatment costs led to a discounted cost savings of £3.7 million. Deterministic sensitivity analysis and 94% of simulations on PSA (threshold £20000) indicated that population screening is cost-effective, compared with current NHS policy. CONCLUSION Population-based screening for BRCA mutations is highly cost-effective compared with an FH-based approach in AJ women age 30 years and older.
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Affiliation(s)
- Ranjit Manchanda
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Rosa Legood
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Matthew Burnell
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Alistair McGuire
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Maria Raikou
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Kelly Loggenberg
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Jane Wardle
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Saskia Sanderson
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Sue Gessler
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Lucy Side
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Nyala Balogun
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Rakshit Desai
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Ajith Kumar
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Huw Dorkins
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Yvonne Wallis
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Cyril Chapman
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Rohan Taylor
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Chris Jacobs
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Ian Tomlinson
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Uziel Beller
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Usha Menon
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ)
| | - Ian Jacobs
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK, (RM); Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, UK (RM, MB, KL, SG, LS, NB, RD, UM, IJ); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (RL); Department of Health Economics, London School of Economics, Houghton Street, London, UK (AM, MR); Behavioural Sciences Unit, Department of Epidemiology and Public Health, University College London, London, UK (JW); Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY (SS); Department of Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London, UK (AK); NW Thames Regional Genetics Service, Kennedy Galton Centre, Middlesex, UK (HD); West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK (YW); Department of Clinical Genetics, West Midlands Regional Genetics Service, Birmingham Women's NHS Foundation Trust, Birmingham, UK (CC); South West Thames Molecular Genetics Diagnostic Laboratory, St George's University of London, London, UK (RT); Department of Clinical Genetics, Guy's Hospital, London, UK (CJ); Welcome Trust Centre for Human Genetics, Roosevelt Drive, Headington Oxford, UK (IT); Department Gynaecology, Shaare Zedek Medical Centre, The Hebrew University of Jerusalem, Jerusalem, Israel (UB); School of Medicine, Faculty of Medical and Human Sciences & Manchester Academic Health Science Center, University of Manchester, Manchester, UK (IJ).
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Polite BN, Griggs JJ, Moy B, Lathan C, duPont NC, Villani G, Wong SL, Halpern MT. American Society of Clinical Oncology policy statement on medicaid reform. J Clin Oncol 2014; 32:4162-7. [PMID: 25403206 PMCID: PMC4879717 DOI: 10.1200/jco.2014.56.3452] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Blase N Polite
- Blase N. Polite, University of Chicago, Chicago, IL; Jennifer J. Griggs and Sandra L. Wong, University of Michigan, Ann Arbor, MI; Beverly Moy, Massachusetts General Hospital; Christopher Lathan, Dana-Farber Cancer Institute, Boston, MA; Nefertiti C. duPont, Roswell Park Cancer Institute, Buffalo; Gina Villani, Ralph Lauren Center for Cancer Care and Prevention, New York, NY; and Michael T. Halpern, RTI International, Washington, DC.
| | - Jennifer J Griggs
- Blase N. Polite, University of Chicago, Chicago, IL; Jennifer J. Griggs and Sandra L. Wong, University of Michigan, Ann Arbor, MI; Beverly Moy, Massachusetts General Hospital; Christopher Lathan, Dana-Farber Cancer Institute, Boston, MA; Nefertiti C. duPont, Roswell Park Cancer Institute, Buffalo; Gina Villani, Ralph Lauren Center for Cancer Care and Prevention, New York, NY; and Michael T. Halpern, RTI International, Washington, DC
| | - Beverly Moy
- Blase N. Polite, University of Chicago, Chicago, IL; Jennifer J. Griggs and Sandra L. Wong, University of Michigan, Ann Arbor, MI; Beverly Moy, Massachusetts General Hospital; Christopher Lathan, Dana-Farber Cancer Institute, Boston, MA; Nefertiti C. duPont, Roswell Park Cancer Institute, Buffalo; Gina Villani, Ralph Lauren Center for Cancer Care and Prevention, New York, NY; and Michael T. Halpern, RTI International, Washington, DC
| | - Christopher Lathan
- Blase N. Polite, University of Chicago, Chicago, IL; Jennifer J. Griggs and Sandra L. Wong, University of Michigan, Ann Arbor, MI; Beverly Moy, Massachusetts General Hospital; Christopher Lathan, Dana-Farber Cancer Institute, Boston, MA; Nefertiti C. duPont, Roswell Park Cancer Institute, Buffalo; Gina Villani, Ralph Lauren Center for Cancer Care and Prevention, New York, NY; and Michael T. Halpern, RTI International, Washington, DC
| | - Nefertiti C duPont
- Blase N. Polite, University of Chicago, Chicago, IL; Jennifer J. Griggs and Sandra L. Wong, University of Michigan, Ann Arbor, MI; Beverly Moy, Massachusetts General Hospital; Christopher Lathan, Dana-Farber Cancer Institute, Boston, MA; Nefertiti C. duPont, Roswell Park Cancer Institute, Buffalo; Gina Villani, Ralph Lauren Center for Cancer Care and Prevention, New York, NY; and Michael T. Halpern, RTI International, Washington, DC
| | - Gina Villani
- Blase N. Polite, University of Chicago, Chicago, IL; Jennifer J. Griggs and Sandra L. Wong, University of Michigan, Ann Arbor, MI; Beverly Moy, Massachusetts General Hospital; Christopher Lathan, Dana-Farber Cancer Institute, Boston, MA; Nefertiti C. duPont, Roswell Park Cancer Institute, Buffalo; Gina Villani, Ralph Lauren Center for Cancer Care and Prevention, New York, NY; and Michael T. Halpern, RTI International, Washington, DC
| | - Sandra L Wong
- Blase N. Polite, University of Chicago, Chicago, IL; Jennifer J. Griggs and Sandra L. Wong, University of Michigan, Ann Arbor, MI; Beverly Moy, Massachusetts General Hospital; Christopher Lathan, Dana-Farber Cancer Institute, Boston, MA; Nefertiti C. duPont, Roswell Park Cancer Institute, Buffalo; Gina Villani, Ralph Lauren Center for Cancer Care and Prevention, New York, NY; and Michael T. Halpern, RTI International, Washington, DC
| | - Michael T Halpern
- Blase N. Polite, University of Chicago, Chicago, IL; Jennifer J. Griggs and Sandra L. Wong, University of Michigan, Ann Arbor, MI; Beverly Moy, Massachusetts General Hospital; Christopher Lathan, Dana-Farber Cancer Institute, Boston, MA; Nefertiti C. duPont, Roswell Park Cancer Institute, Buffalo; Gina Villani, Ralph Lauren Center for Cancer Care and Prevention, New York, NY; and Michael T. Halpern, RTI International, Washington, DC
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McCann GA, Eisenhauer EL. Hereditary cancer syndromes with high risk of endometrial and ovarian cancer: surgical options for personalized care. J Surg Oncol 2014; 111:118-24. [PMID: 25139656 DOI: 10.1002/jso.23743] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 07/11/2014] [Indexed: 12/14/2022]
Abstract
Cancer genomics has increased our recognition of specific hereditary cancer mutations. Hereditary breast and ovarian cancer (HBOC) syndrome and Lynch syndrome are two such entities in which women carrying specific mutations may be at high risk for developing breast, ovarian, and/or endometrial cancers. Risk reducing surgery such as prophylactic mastectomy, oophorectomy, and/or hysterectomy may allow women to decrease these risks after completing childbearing. Background, indications, and consequences of these procedures are reviewed.
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Affiliation(s)
- Georgia A McCann
- Department of Obstetrics and Gynecology, University Of Texas Health Science Center, San Antonio, Texas
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Giardiello FM, Allen JI, Axilbund JE, Boland CR, Burke CA, Burt RW, Church JM, Dominitz JA, Johnson DA, Kaltenbach T, Levin TR, Lieberman DA, Robertson DJ, Syngal S, Rex DK. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the US Multi-Society Task Force on colorectal cancer. Gastroenterology 2014; 147:502-26. [PMID: 25043945 DOI: 10.1053/j.gastro.2014.04.001] [Citation(s) in RCA: 337] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The Multi-Society Task Force, in collaboration with invited experts, developed guidelines to assist health care providers with the appropriate provision of genetic testing and management of patients at risk for and affected with Lynch syndrome as follows: Figure 1 provides a colorectal cancer risk assessment tool to screen individuals in the office or endoscopy setting; Figure 2 illustrates a strategy for universal screening for Lynch syndrome by tumor testing of patients diagnosed with colorectal cancer; Figures 3-6 provide algorithms for genetic evaluation of affected and at-risk family members of pedigrees with Lynch syndrome; Table 10 provides guidelines for screening at-risk and affected persons with Lynch syndrome; and Table 12 lists the guidelines for the management of patients with Lynch syndrome. A detailed explanation of Lynch syndrome and the methodology utilized to derive these guidelines, as well as an explanation of, and supporting literature for, these guidelines are provided.
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Affiliation(s)
| | - John I Allen
- Yale University School of Medicine, New Haven, Connecticut
| | | | | | | | | | | | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington; University of Washington, Seattle, Washington
| | | | | | | | | | - Douglas J Robertson
- White River Junction VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, White River Junction, Vermont
| | - Sapna Syngal
- Brigham and Women's Hospital, Boston, Massachusetts; Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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36
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Giardiello FM, Allen JI, Axilbund JE, Boland CR, Burke CA, Burt RW, Church JM, Dominitz JA, Johnson DA, Kaltenbach T, Levin TR, Lieberman DA, Robertson DJ, Syngal S, Rex DK. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the U.S. Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2014; 80:197-220. [PMID: 25034835 DOI: 10.1016/j.gie.2014.06.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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37
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Giardiello FM, Allen JI, Axilbund JE, Boland CR, Burke CA, Burt RW, Church JM, Dominitz JA, Johnson DA, Kaltenbach T, Levin TR, Lieberman DA, Robertson DJ, Syngal S, Rex DK. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the US Multi-society Task Force on colorectal cancer. Am J Gastroenterol 2014; 109:1159-79. [PMID: 25070057 DOI: 10.1038/ajg.2014.186] [Citation(s) in RCA: 312] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The Multi-Society Task Force, in collaboration with invited experts, developed guidelines to assist health care providers with the appropriate provision of genetic testing and management of patients at risk for and affected with Lynch syndrome as follows: Figure 1 provides a colorectal cancer risk assessment tool to screen individuals in the office or endoscopy setting; Figure 2 illustrates a strategy for universal screening for Lynch syndrome by tumor testing of patients diagnosed with colorectal cancer; Figures 3,4,5,6 provide algorithms for genetic evaluation of affected and at-risk family members of pedigrees with Lynch syndrome; Table 10 provides guidelines for screening at-risk and affected persons with Lynch syndrome; and Table 12 lists the guidelines for the management of patients with Lynch syndrome. A detailed explanation of Lynch syndrome and the methodology utilized to derive these guidelines, as well as an explanation of, and supporting literature for, these guidelines are provided.
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Affiliation(s)
| | - John I Allen
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | | | | | | | | | - Jason A Dominitz
- 1] VA Puget Sound Health Care System, Seattle, Washington, USA [2] University of Washington, Seattle, Washington, USA
| | | | | | | | | | - Douglas J Robertson
- 1] White River Junction VA Medical Center, White River Junction, Vermont, USA [2] Geisel School of Medicine at Dartmouth, White River Junction, Vermont, USA
| | - Sapna Syngal
- 1] Brigham and Women's Hospital, Boston, Massachusetts, USA [2] Dana Farber Cancer Institute, Boston, Massachusetts, USA [3] Harvard Medical School, Boston, Massachusetts, USA
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Matro JM, Ruth KJ, Wong YN, McCully KC, Rybak CM, Meropol NJ, Hall MJ. Cost sharing and hereditary cancer risk: predictors of willingness-to-pay for genetic testing. J Genet Couns 2014; 23:1002-11. [PMID: 24794065 DOI: 10.1007/s10897-014-9724-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 04/09/2014] [Indexed: 12/19/2022]
Abstract
Increasing use of predictive genetic testing to gauge hereditary cancer risk has been paralleled by rising cost-sharing practices. Little is known about how demographic and psychosocial factors may influence individuals' willingness-to-pay for genetic testing. The Gastrointestinal Tumor Risk Assessment Program Registry includes individuals presenting for genetic risk assessment based on personal/family cancer history. Participants complete a baseline survey assessing cancer history and psychosocial items. Willingness-to-pay items include intention for: genetic testing only if paid by insurance; testing with self-pay; and amount willing-to-pay ($25-$2,000). Multivariable models examined predictors of willingness-to-pay out-of-pocket (versus only if paid by insurance) and willingness-to-pay a smaller versus larger sum (≤$200 vs. ≥$500). All statistical tests are two-sided (α = 0.05). Of 385 evaluable participants, a minority (42%) had a personal cancer history, while 56% had ≥1 first-degree relative with colorectal cancer. Overall, 21.3% were willing to have testing only if paid by insurance, and 78.7% were willing-to-pay. Predictors of willingness-to-pay were: 1) concern for positive result; 2) confidence to control cancer risk; 3) fewer perceived barriers to colorectal cancer screening; 4) benefit of testing to guide screening (all p < 0.05). Subjects willing-to-pay a higher amount were male, more educated, had greater cancer worry, fewer relatives with colorectal cancer, and more positive attitudes toward genetic testing (all p < 0.05). Individuals seeking risk assessment are willing-to-pay out-of-pocket for genetic testing, and anticipate benefits to reducing cancer risk. Identifying factors associated with willingness-to-pay for genetic services is increasingly important as testing is integrated into routine cancer care.
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Affiliation(s)
- Jennifer M Matro
- Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA,
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Downes MR, Allo G, McCluggage WG, Sy K, Ferguson SE, Aronson M, Pollett A, Gallinger S, Bilbily E, Shaw P, Clarke BA. Review of findings in prophylactic gynaecological specimens in Lynch syndrome with literature review and recommendations for grossing. Histopathology 2014; 65:228-39. [PMID: 24495259 DOI: 10.1111/his.12386] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/30/2014] [Indexed: 12/25/2022]
Abstract
AIMS Prophylactic hysterectomy with bilateral salpingo-oophorectomy is being increasingly undertaken in patients with Lynch syndrome (LS). The pathological features in such specimens are not well described and, unlike the SEE-FIM protocol for salpingo-oophorectomy specimens in BRCA1/2 mutation carriers and the gastrectomy grossing protocols for patients with CDH1 (E-cadherin) mutations, guidelines have not been devised for the grossing of prophylactic gynaecological specimens from LS patients. We aimed to review the pathological findings in a series of prophylactic gynaecological specimens from LS patients and develop guidelines for the grossing of these specimens. METHODS AND RESULTS We reviewed the pathological findings in 25 prophylactic gynaecological specimens from LS patients and audited the grossing protocols in different centres across Ontario, Canada. We found a 32% incidence of endometrial carcinoma or a precursor lesion; the two endometrial cancers identified were low-grade, low-stage endometrioid adenocarcinomas. To address the absence of guidelines for pathological examination, we undertook a literature review of gynaecological malignancies and incidental findings in prophylactic specimens in LS patients. CONCLUSION We provide recommendations regarding the grossing of such specimens which includes in-toto examination of the lower uterine segment, endometrium, ovaries and fallopian tubes with representative sampling of the cervix.
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Affiliation(s)
- Michelle R Downes
- Department of Pathology, University Health Network, Toronto, ON, Canada
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Lu KH, Daniels M. Endometrial and ovarian cancer in women with Lynch syndrome: update in screening and prevention. Fam Cancer 2014; 12:273-7. [PMID: 23765559 DOI: 10.1007/s10689-013-9664-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Women with Lynch syndrome have an additional need to address the substantial increased lifetime risk of endometrial and ovarian cancer. Endometrial or ovarian cancer can be the presenting cancer in individuals with Lynch syndrome, or can be a second cancer. Lifetime risk of endometrial cancer in women with MLH1 or MSH2 mutations is approximately 40 %, with a median age of 49. Women with MSH6 mutations have a similar risk of endometrial cancer but a later age of diagnosis. Lynch syndrome-associated endometrial cancers are primarily endometrioid, although non-endometrioid subtypes including clear cell, papillary serous and MMMT have been reported. In addition, endometrial cancers arising in the lower uterine segment, while rare in the general population, are enriched in women with Lynch syndrome. Ovarian cancer risk in women with Lynch syndrome is 6-8 %, and Lynch syndrome-associated ovarian cancers exhibit a variety of histopathological subtypes. Studies of endometrial cancer screening in Lynch syndrome have been small, and more recently have focused on the use of office endometrial biopsy to identify pre-malignant and early stage cancers. Prevention options include the use of oral contraceptives, which are known to be highly effective for decreasing risk of both endometrial and ovarian cancer in the general population, and prophylactic surgery to remove the uterus and ovaries.
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Affiliation(s)
- Karen H Lu
- H.E.B. Professor of Cancer Research, Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Stewart A. Genetic testing strategies in newly diagnosed endometrial cancer patients aimed at reducing morbidity or mortality from lynch syndrome in the index case or her relatives. PLOS CURRENTS 2013; 5:ecurrents.eogt.b59a6e84f27c536e50db4e46aa26309c. [PMID: 24056992 PMCID: PMC3775889 DOI: 10.1371/currents.eogt.b59a6e84f27c536e50db4e46aa26309c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Endometrial cancer is the first malignancy in 50% of women with Lynch syndrome, an autosomal dominant cancer-prone syndrome caused by germline mutations in genes encoding components of the DNA mismatch repair (MMR) pathway. These women (2-4% of all those with endometrial cancer) are at risk of metachronous colorectal cancer and other Lynch syndrome-associated cancers, and their first-degree relatives are at 50% risk of Lynch syndrome. Testing all women newly diagnosed with endometrial cancer for Lynch syndrome may have clinical utility for the index case and her relatives by alerting them to the benefits of surveillance and preventive options, primarily for colorectal cancer. The strategy involves offering germline DNA mutation testing to those whose tumour shows loss-of-function of MMR protein(s) when analysed for microsatellite instability (MSI) and/or by immunohistochemisty (IHC). In endometrial tumours from unselected patients, MSI and IHC have a sensitivity of 80-100% and specificity of 60-80% for detecting a mutation in an MMR gene, though the number of suitable studies for determining clinical validity is small. The clinical validity of strategies to exclude those with false-positive tumour test results due to somatic hypermethylation of the MLH1 gene promoter has not been determined. Options include direct methylation testing, and excluding those over the age of 60 who have no concerning family history or clinical features. The clinical utility of Lynch syndrome testing for the index case depends on her age and the MMR gene mutated: the net benefit is lower for those diagnosed at older ages and with less-penetrant MSH6 mutations. To date, women with these features are the majority of those diagnosed through screening unselected endometrial cancer patients but the number of studies is small. Similarly, clinical utility to relatives of the index case is higher if the family's mutation is in MLH1 or MSH2 than for MSH6 or PMS2. Gaps in current evidence include a need for large, prospective studies on unselected endometrial cancer patients, and for health-economic analysis based on appropriate assumptions.
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Affiliation(s)
- Alison Stewart
- (1) McKing Consulting Corp., and (2) Centers for Disease Control and Prevention
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Abstract
Women with Lynch syndrome (LS) are at increased risk for endometrial (EC) and ovarian carcinoma (OC). Current surveillance recommendations for detection of EC and OC in LS patients are not effective. Small studies have shown that prophylactic hysterectomy and bilateral salpingo-oophorectomy (P-TH-BSO) are the most effective and least expensive preventive measures in these patients. Data regarding histologic findings in prophylactic specimens in these patients are lacking. All LS patients who underwent P-TH-BSO at the Memorial Sloan-Kettering Cancer Center from 2000 to 2011 were identified. Slides were evaluated for the presence of endometrial hyperplasia (EH), EC, OC, or any other recurrent histologic findings. Twenty-five patients were identified, with an age range of 36 to 61 years. Fifteen patients had a synchronous or prior colorectal carcinoma, and 2 patients had a history of sebaceous carcinoma. Focal FIGO grade 1 endometrioid ECs were detected in 2 patients; 1 was 54 years of age (MSH2 mutation; superficially invasive), and the other was 56 years of age (MLH1 mutation; noninvasive). Focal complex atypical hyperplasia, unassociated with carcinoma, was seen in 3 patients, ages 35 and 45 (MLH1 mutations) and 53 years (MSH2 mutation). One patient (44 y, with MSH2 mutation) was found to have a mixed endometrioid/clear cell OC and simple EH without atypia. The OC was adherent to the colon but did not show distant metastasis. In our study, P-TH-BSOs performed because of the presence of LS revealed incidental EC and/or EH in 24% of cases and OC in 4%. The ECs were low grade, confined to the endometrium, and seen in patients older than 50 years. Prophylactic hysterectomy allows detection of early lesions in LS; these lesions appear to be small and focal. This small series of prophylactic hysterectomies may provide some clues about LS-associated endometrial carcinogenesis.
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43
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Folkins AK, Longacre TA. Hereditary gynaecological malignancies: advances in screening and treatment. Histopathology 2012; 62:2-30. [DOI: 10.1111/his.12028] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Ann K Folkins
- Department of Pathology; Stanford University School of Medicine; Stanford; CA; USA
| | - Teri A Longacre
- Department of Pathology; Stanford University School of Medicine; Stanford; CA; USA
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Yurgelun MB, Mercado R, Rosenblatt M, Dandapani M, Kohlmann W, Conrad P, Blanco A, Shannon KM, Chung DC, Terdiman J, Gruber SB, Garber JE, Syngal S, Stoffel EM. Impact of genetic testing on endometrial cancer risk-reducing practices in women at risk for Lynch syndrome. Gynecol Oncol 2012; 127:544-51. [PMID: 22940489 DOI: 10.1016/j.ygyno.2012.08.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 08/17/2012] [Accepted: 08/19/2012] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Due to the increased lifetime risk of endometrial cancer (EC), guidelines recommend that women with Lynch syndrome (LS) age ≥ 35 undergo annual EC surveillance or prophylactic hysterectomy (PH). The aim of this study was to examine the uptake of these risk-reducing strategies. METHODS The study population included women meeting clinical criteria for genetic evaluation for LS. Data on cancer risk-reducing behaviors were collected from subjects enrolled in two distinct studies: (1) a multicenter cross-sectional study involving completion of a one-time questionnaire, or (2) a single-center longitudinal study in which subjects completed questionnaires before and after undergoing genetic testing. The main outcome was uptake of EC risk-reducing practices. RESULTS In the cross-sectional cohort, 58/77 (75%) women at risk for LS-associated EC reported engaging in EC risk-reduction. Personal history of genetic testing was associated with uptake of EC surveillance or PH (OR 17.1; 95% CI 4.1-70.9). Prior to genetic testing for LS, 26/40 (65%) women in the longitudinal cohort reported engaging in EC risk-reduction. At one-year follow-up, 16/16 (100%) mismatch repair (MMR) gene mutation carriers were adherent to guidelines for EC risk-reduction, 9 (56%) of whom had undergone PH. By three-year follow-up, 11/16 (69%) MMR mutation carriers had undergone PH. Among women with negative or uninformative genetic test results, none underwent PH after testing. CONCLUSIONS Genetic testing for LS is strongly associated with uptake of EC risk-reducing practices. Women found to have LS in this study underwent prophylactic gynecologic surgery at rates comparable to those published for BRCA1/2 mutation carriers.
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Stuckless S, Green J, Dawson L, Barrett B, Woods MO, Dicks E, Parfrey PS. Impact of gynecological screening in Lynch syndrome carriers with an MSH2 mutation. Clin Genet 2012; 83:359-64. [PMID: 22775459 DOI: 10.1111/j.1399-0004.2012.01929.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 07/04/2012] [Indexed: 01/11/2023]
Abstract
Lifetime risk of developing endometrial cancer in Lynch syndrome carriers is very high and females are also at an increased risk of developing ovarian cancer. The aim of the study was to determine the impact of gynecological screening in MSH2 mutation carriers. Gynecological cancer incidence and overall survival was compared in female mutation carriers who received gynecological screening (cases) and in matched controls. Controls were randomly selected from non-screened mutation carriers who were alive and disease-free at the age the case entered the screening program. Median age to diagnosis of gynecological cancer was 54 years in the screened group compared to 56 years in controls (p = 0.50). Stage I or II cancer was diagnosed in 92% of screened patients compared to 71% in the control group (p = 0.17). Two of three deaths in the screened group were the result of ovarian cancer. Mean survival in the screened group was 79 years compared to 69 years in the control group (p = 0.11), likely associated with concomitant colonoscopy screening. Gynecological screening did not result in earlier gynecologic cancer detection and despite screening two young women died from ovarian cancer suggesting that prophylactic hysterectomy with bilateral salpingo-oophorectomy be considered in female mutation carriers who have completed childbearing.
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Affiliation(s)
- S Stuckless
- Clinical Epidemiology Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada.
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Gong P, Charles S, Rosenblum N, Wang Z, Witkiewicz AK. A case of endometrial cancer in the context of a BRCA2 mutation and double heterozygosity for Lynch syndrome. GYNECOLOGIC ONCOLOGY CASE REPORTS 2012; 2:69-72. [PMID: 24371622 DOI: 10.1016/j.gynor.2012.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 03/01/2012] [Indexed: 01/30/2023]
Abstract
► Endometrial cancer with BRCA2 mutation and double heterozygosity for Lynch syndrome. ► Loss of MLH1 and PMS2 by immunohistochemical stain. ► MSH1 and MSH6 gene mutations by genomic sequencing.
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Affiliation(s)
- Ping Gong
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Sarah Charles
- Kimmel Cancer Center, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Norman Rosenblum
- Gynecologic Oncology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Zoe Wang
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Agnieszka K Witkiewicz
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
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Grandval P, Baert-Desurmont S, Bonnet F, Bronner M, Buisine MP, Colas C, Noguchi T, North MO, Rey JM, Tinat J, Toulas C, Olschwang S. Colon-specific phenotype in Lynch syndrome associated with EPCAM deletion. Clin Genet 2012; 82:97-9. [PMID: 22243433 DOI: 10.1111/j.1399-0004.2011.01826.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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