1
|
Moss E, Taylor A, Andreou A, Ang C, Arora R, Attygalle A, Banerjee S, Bowen R, Buckley L, Burbos N, Coleridge S, Edmondson R, El-Bahrawy M, Fotopoulou C, Frost J, Ganesan R, George A, Hanna L, Kaur B, Manchanda R, Maxwell H, Michael A, Miles T, Newton C, Nicum S, Ratnavelu N, Ryan N, Sundar S, Vroobel K, Walther A, Wong J, Morrison J. British Gynaecological Cancer Society (BGCS) ovarian, tubal and primary peritoneal cancer guidelines: Recommendations for practice update 2024. Eur J Obstet Gynecol Reprod Biol 2024; 300:69-123. [PMID: 39002401 DOI: 10.1016/j.ejogrb.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 07/15/2024]
Affiliation(s)
- Esther Moss
- College of Life Sciences, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | | | - Adrian Andreou
- Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, UK
| | - Christine Ang
- Northern Gynaecological Oncology Centre, Gateshead, UK
| | - Rupali Arora
- Department of Cellular Pathology, University College London NHS Trust, 60 Whitfield Street, London W1T 4E, UK
| | | | | | - Rebecca Bowen
- Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, UK
| | - Lynn Buckley
- Beverley Counselling & Psychotherapy, 114 Holme Church Lane, Beverley, East Yorkshire HU17 0PY, UK
| | - Nikos Burbos
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital Colney Lane, Norwich NR4 7UY, UK
| | | | - Richard Edmondson
- Saint Mary's Hospital, Manchester and University of Manchester, M13 9WL, UK
| | - Mona El-Bahrawy
- Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | | | - Jonathan Frost
- Gynaecological Oncology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, Bath BA1 3NG, UK; University of Exeter, Exeter, UK
| | - Raji Ganesan
- Department of Cellular Pathology, Birmingham Women's Hospital, Birmingham B15 2TG, UK
| | | | - Louise Hanna
- Department of Oncology, Velindre Cancer Centre, Whitchurch, Cardiff CF14 2TL, UK
| | - Baljeet Kaur
- North West London Pathology (NWLP), Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Ranjit Manchanda
- Wolfson Institute of Population Health, Cancer Research UK Barts Centre, Queen Mary University of London and Barts Health NHS Trust, UK
| | - Hillary Maxwell
- Dorset County Hospital, Williams Avenue, Dorchester, Dorset DT1 2JY, UK
| | - Agnieszka Michael
- Royal Surrey NHS Foundation Trust, Guildford GU2 7XX and University of Surrey, School of Biosciences, GU2 7WG, UK
| | - Tracey Miles
- Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, UK
| | - Claire Newton
- Gynaecology Oncology Department, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol BS1 3NU, UK
| | - Shibani Nicum
- Department of Oncology, University College London Cancer Institute, London, UK
| | | | - Neil Ryan
- The Centre for Reproductive Health, Institute for Regeneration and Repair (IRR), 4-5 Little France Drive, Edinburgh BioQuarter City, Edinburgh EH16 4UU, UK
| | - Sudha Sundar
- Institute of Cancer and Genomic Sciences, University of Birmingham and Pan Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham B18 7QH, UK
| | - Katherine Vroobel
- Department of Cellular Pathology, Royal Marsden Foundation NHS Trust, London SW3 6JJ, UK
| | - Axel Walther
- Bristol Cancer Institute, University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - Jason Wong
- Department of Histopathology, East Suffolk and North Essex NHS Foundation Trust, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, UK
| | - Jo Morrison
- University of Exeter, Exeter, UK; Department of Gynaecological Oncology, GRACE Centre, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton TA1 5DA, UK.
| |
Collapse
|
2
|
Ring KL. The Intersection of Endometriosis and Ovarian Cancer Prevention. JAMA Surg 2024:2822319. [PMID: 39141359 DOI: 10.1001/jamasurg.2024.2974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Affiliation(s)
- Kari L Ring
- Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville
| |
Collapse
|
3
|
Oxley SG, Wei X, Sideris M, Blyuss O, Kalra A, Sia JJY, Ganesan S, Fierheller CT, Sun L, Sadique Z, Jin H, Manchanda R, Legood R. Utility Scores for Risk-Reducing Mastectomy and Risk-Reducing Salpingo-Oophorectomy: Mapping to EQ-5D. Cancers (Basel) 2024; 16:1358. [PMID: 38611036 PMCID: PMC11010846 DOI: 10.3390/cancers16071358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Risk-reducing mastectomy (RRM) and risk-reducing salpingo-oophorectomy (RRSO) are the most effective breast and ovarian cancer preventive interventions. EQ-5D is the recommended tool to assess the quality of life and determine health-related utility scores (HRUSs), yet there are no published EQ-5D HRUSs after these procedures. These are essential for clinicians counselling patients and for health-economic evaluations. METHODS We used aggregate data from our published systematic review and converted SF-36/SF-12 summary scores to EQ-5D HRUSs using a published mapping algorithm. Study control arm or age-matched country-specific reference values provided comparison. Random-effects meta-analysis provided adjusted disutilities and utility scores. Subgroup analyses included long-term vs. short-term follow-up. RESULTS Four studies (209 patients) reported RRM outcomes using SF-36, and five studies (742 patients) reported RRSO outcomes using SF-12/SF-36. RRM is associated with a long-term (>2 years) disutility of -0.08 (95% CI -0.11, -0.04) (I2 31.4%) and a utility of 0.92 (95% CI 0.88, 0.95) (I2 31.4%). RRSO is associated with a long-term (>1 year) disutility of -0.03 (95% CI -0.05, 0.00) (I2 17.2%) and a utility of 0.97 (95% CI 0.94, 0.99) (I2 34.0%). CONCLUSIONS We present the first HRUSs sourced from patients following RRM and RRSO. There is a need for high-quality prospective studies to characterise quality of life at different timepoints.
Collapse
Affiliation(s)
- Samuel G. Oxley
- Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK; (S.G.O.); (X.W.); (M.S.); (O.B.); (A.K.); (J.J.Y.S.); (S.G.); (C.T.F.)
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, UK
| | - Xia Wei
- Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK; (S.G.O.); (X.W.); (M.S.); (O.B.); (A.K.); (J.J.Y.S.); (S.G.); (C.T.F.)
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK; (L.S.); (Z.S.)
| | - Michail Sideris
- Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK; (S.G.O.); (X.W.); (M.S.); (O.B.); (A.K.); (J.J.Y.S.); (S.G.); (C.T.F.)
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, UK
| | - Oleg Blyuss
- Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK; (S.G.O.); (X.W.); (M.S.); (O.B.); (A.K.); (J.J.Y.S.); (S.G.); (C.T.F.)
- Department of Pediatrics and Pediatric Infectious Diseases, Institute of Child´s Health, Sechenov First Moscow State Medical University, Sechenov University, Moscow 119991, Russia
| | - Ashwin Kalra
- Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK; (S.G.O.); (X.W.); (M.S.); (O.B.); (A.K.); (J.J.Y.S.); (S.G.); (C.T.F.)
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, UK
| | - Jacqueline J. Y. Sia
- Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK; (S.G.O.); (X.W.); (M.S.); (O.B.); (A.K.); (J.J.Y.S.); (S.G.); (C.T.F.)
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, UK
| | - Subhasheenee Ganesan
- Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK; (S.G.O.); (X.W.); (M.S.); (O.B.); (A.K.); (J.J.Y.S.); (S.G.); (C.T.F.)
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, UK
| | - Caitlin T. Fierheller
- Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK; (S.G.O.); (X.W.); (M.S.); (O.B.); (A.K.); (J.J.Y.S.); (S.G.); (C.T.F.)
| | - Li Sun
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK; (L.S.); (Z.S.)
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK; (L.S.); (Z.S.)
| | - Haomiao Jin
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7YH, UK;
| | - Ranjit Manchanda
- Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK; (S.G.O.); (X.W.); (M.S.); (O.B.); (A.K.); (J.J.Y.S.); (S.G.); (C.T.F.)
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, UK
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK; (L.S.); (Z.S.)
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, Faculty of Population Health Sciences, University College London, London WC1V 6LJ, UK
| | - Rosa Legood
- Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK; (S.G.O.); (X.W.); (M.S.); (O.B.); (A.K.); (J.J.Y.S.); (S.G.); (C.T.F.)
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK; (L.S.); (Z.S.)
| |
Collapse
|
4
|
Sideris M, Menon U, Manchanda R. Screening and prevention of ovarian cancer. Med J Aust 2024; 220:264-274. [PMID: 38353066 DOI: 10.5694/mja2.52227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 12/11/2023] [Indexed: 03/07/2024]
Abstract
Ovarian cancer remains the most lethal gynaecological malignancy with 314 000 cases and 207 000 deaths annually worldwide. Ovarian cancer cases and deaths are predicted to increase in Australia by 42% and 55% respectively by 2040. Earlier detection and significant downstaging of ovarian cancer have been demonstrated with multimodal screening in the largest randomised controlled trial of ovarian cancer screening in women at average population risk. However, none of the randomised trials have demonstrated a mortality benefit. Therefore, ovarian cancer screening is not currently recommended in women at average population risk. More frequent surveillance for ovarian cancer every three to four months in women at high risk has shown good performance characteristics and significant downstaging, but there is no available information on a survival benefit. Population testing offers an emerging novel strategy to identify women at high risk who can benefit from ovarian cancer prevention. Novel multicancer early detection biomarker, longitudinal multiple marker strategies, and new biomarkers are being investigated and evaluated for ovarian cancer screening. Risk-reducing salpingo-oophorectomy (RRSO) decreases ovarian cancer incidence and mortality and is recommended for women at over a 4-5% lifetime risk of ovarian cancer. Pre-menopausal women without contraindications to hormone replacement therapy (HRT) undergoing RRSO should be offered HRT until 51 years of age to minimise the detrimental consequences of premature menopause. Currently risk-reducing early salpingectomy and delayed oophorectomy (RRESDO) should only be offered to women at increased risk of ovarian cancer within the context of a research trial. Pre-menopausal early salpingectomy is associated with fewer menopausal symptoms and better sexual function than bilateral salpingo-oophorectomy. A Sectioning and Extensively Examining the Fimbria (SEE-FIM) protocol should be used for histopathological assessment in women at high risk of ovarian cancer who are undergoing surgical prevention. Opportunistic salpingectomy may be offered at routine gynaecological surgery to all women who have completed their family. Long term prospective opportunistic salpingectomy studies are needed to determine the effect size of ovarian cancer risk reduction and the impact on menopause.
Collapse
Affiliation(s)
- Michail Sideris
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Usha Menon
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Ranjit Manchanda
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Institute of Clinical Trials and Methodology, University College London, London, UK
- Barts Health NHS Trust, London, UK
- London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
5
|
Wei X, Sun L, Slade E, Fierheller CT, Oxley S, Kalra A, Sia J, Sideris M, McCluggage WG, Bromham N, Dworzynski K, Rosenthal AN, Brentnall A, Duffy S, Evans DG, Yang L, Legood R, Manchanda R. Cost-Effectiveness of Gene-Specific Prevention Strategies for Ovarian and Breast Cancer. JAMA Netw Open 2024; 7:e2355324. [PMID: 38334999 PMCID: PMC10858404 DOI: 10.1001/jamanetworkopen.2023.55324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/16/2023] [Indexed: 02/10/2024] Open
Abstract
Importance Pathogenic variants (PVs) in BRCA1, BRCA2, PALB2, RAD51C, RAD51D, and BRIP1 cancer susceptibility genes (CSGs) confer an increased ovarian cancer (OC) risk, with BRCA1, BRCA2, PALB2, RAD51C, and RAD51D PVs also conferring an elevated breast cancer (BC) risk. Risk-reducing surgery, medical prevention, and BC surveillance offer the opportunity to prevent cancers and deaths, but their cost-effectiveness for individual CSGs remains poorly addressed. Objective To estimate the cost-effectiveness of prevention strategies for OC and BC among individuals carrying PVs in the previously listed CSGs. Design, Setting, and Participants In this economic evaluation, a decision-analytic Markov model evaluated the cost-effectiveness of risk-reducing salpingo-oophorectomy (RRSO) and, where relevant, risk-reducing mastectomy (RRM) compared with nonsurgical interventions (including BC surveillance and medical prevention for increased BC risk) from December 1, 2022, to August 31, 2023. The analysis took a UK payer perspective with a lifetime horizon. The simulated cohort consisted of women aged 30 years who carried BRCA1, BRCA2, PALB2, RAD51C, RAD51D, or BRIP1 PVs. Appropriate sensitivity and scenario analyses were performed. Exposures CSG-specific interventions, including RRSO at age 35 to 50 years with or without BC surveillance and medical prevention (ie, tamoxifen or anastrozole) from age 30 or 40 years, RRM at age 30 to 40 years, both RRSO and RRM, BC surveillance and medical prevention, or no intervention. Main Outcomes and Measures The incremental cost-effectiveness ratio (ICER) was calculated as incremental cost per quality-adjusted life-year (QALY) gained. OC and BC cases and deaths were estimated. Results In the simulated cohort of women aged 30 years with no cancer, undergoing both RRSO and RRM was most cost-effective for individuals carrying BRCA1 (RRM at age 30 years; RRSO at age 35 years), BRCA2 (RRM at age 35 years; RRSO at age 40 years), and PALB2 (RRM at age 40 years; RRSO at age 45 years) PVs. The corresponding ICERs were -£1942/QALY (-$2680/QALY), -£89/QALY (-$123/QALY), and £2381/QALY ($3286/QALY), respectively. RRSO at age 45 years was cost-effective for RAD51C, RAD51D, and BRIP1 PV carriers compared with nonsurgical strategies. The corresponding ICERs were £962/QALY ($1328/QALY), £771/QALY ($1064/QALY), and £2355/QALY ($3250/QALY), respectively. The most cost-effective preventive strategy per 1000 PV carriers could prevent 923 OC and BC cases and 302 deaths among those carrying BRCA1; 686 OC and BC cases and 170 deaths for BRCA2; 464 OC and BC cases and 130 deaths for PALB2; 102 OC cases and 64 deaths for RAD51C; 118 OC cases and 76 deaths for RAD51D; and 55 OC cases and 37 deaths for BRIP1. Probabilistic sensitivity analysis indicated both RRSO and RRM were most cost-effective in 96.5%, 89.2%, and 84.8% of simulations for BRCA1, BRCA2, and PALB2 PVs, respectively, while RRSO was cost-effective in approximately 100% of simulations for RAD51C, RAD51D, and BRIP1 PVs. Conclusions and Relevance In this cost-effectiveness study, RRSO with or without RRM at varying optimal ages was cost-effective compared with nonsurgical strategies for individuals who carried BRCA1, BRCA2, PALB2, RAD51C, RAD51D, or BRIP1 PVs. These findings support personalizing risk-reducing surgery and guideline recommendations for individual CSG-specific OC and BC risk management.
Collapse
Affiliation(s)
- Xia Wei
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Li Sun
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Eric Slade
- National Institute for Health and Care Excellence, London, United Kingdom
| | - Caitlin T. Fierheller
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Samuel Oxley
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
| | - Ashwin Kalra
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
| | - Jacqueline Sia
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
| | - Michail Sideris
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
| | - W. Glenn McCluggage
- Department of Pathology, Belfast Health & Social Care Trust, Royal Victoria Hospital, Belfast, United Kingdom
| | - Nathan Bromham
- National Institute for Health and Care Excellence, London, United Kingdom
| | | | - Adam N. Rosenthal
- Department of Gynaecology, University College London Hospitals NHS Foundation trust, London, United Kingdom
- Department of Women’s Cancer, UCL EGA Institute for Women’s Health, University College London, London, United Kingdom
| | - Adam Brentnall
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Stephen Duffy
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - D. Gareth Evans
- Manchester Centre for Genomic Medicine, Division of Evolution, Infection and Genomic Sciences, University of Manchester, MAHSC, Manchester, United Kingdom
| | - Li Yang
- School of Public Health, Peking University, Beijing, China
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Ranjit Manchanda
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, Faculty of Population Health Sciences, University College London, London, United Kingdom
| |
Collapse
|
6
|
Wei X, Oxley S, Sideris M, Kalra A, Brentnall A, Sun L, Yang L, Legood R, Manchanda R. Quality of life after risk-reducing surgery for breast and ovarian cancer prevention: a systematic review and meta-analysis. Am J Obstet Gynecol 2023; 229:388-409.e4. [PMID: 37059410 DOI: 10.1016/j.ajog.2023.03.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVE This study aimed to assess the impact of risk-reducing surgery for breast cancer and ovarian cancer prevention on quality of life. We considered risk-reducing mastectomy, risk-reducing salpingo-oophorectomy, and risk-reducing early salpingectomy and delayed oophorectomy. DATA SOURCES We followed a prospective protocol (International Prospective Register of Systematic Reviews: CRD42022319782) and searched MEDLINE, Embase, PubMed, and Cochrane Library from inception to February 2023. STUDY ELIGIBILITY CRITERIA We followed a PICOS (population, intervention, comparison, outcome, and study design) framework. The population included women at increased risk of breast cancer or ovarian cancer. We focused on studies reporting quality of life outcomes (health-related quality of life, sexual function, menopause symptoms, body image, cancer-related distress or worry, anxiety, or depression) after risk-reducing surgery, including risk-reducing mastectomy for breast cancer and risk-reducing salpingo-oophorectomy or risk-reducing early salpingectomy and delayed oophorectomy for ovarian cancer. METHODS We used the Methodological Index for Non-Randomized Studies (MINORS) for study appraisal. Qualitative synthesis and fixed-effects meta-analysis were performed. RESULTS A total of 34 studies were included (risk-reducing mastectomy: 16 studies; risk-reducing salpingo-oophorectomy: 19 studies; risk-reducing early salpingectomy and delayed oophorectomy: 2 studies). Health-related quality of life was unchanged or improved in 13 of 15 studies after risk-reducing mastectomy (N=986) and 10 of 16 studies after risk-reducing salpingo-oophorectomy (N=1617), despite short-term deficits (N=96 after risk-reducing mastectomy and N=459 after risk-reducing salpingo-oophorectomy). Sexual function (using the Sexual Activity Questionnaire) was affected in 13 of 16 studies (N=1400) after risk-reducing salpingo-oophorectomy in terms of decreased sexual pleasure (-1.21 [-1.53 to -0.89]; N=3070) and increased sexual discomfort (1.12 [0.93-1.31]; N=1400). Hormone replacement therapy after premenopausal risk-reducing salpingo-oophorectomy was associated with an increase (1.16 [0.17-2.15]; N=291) in sexual pleasure and a decrease (-1.20 [-1.75 to -0.65]; N=157) in sexual discomfort. Sexual function was affected in 4 of 13 studies (N=147) after risk-reducing mastectomy, but stable in 9 of 13 studies (N=799). Body image was unaffected in 7 of 13 studies (N=605) after risk-reducing mastectomy, whereas 6 of 13 studies (N=391) reported worsening. Increased menopause symptoms were reported in 12 of 13 studies (N=1759) after risk-reducing salpingo-oophorectomy with a reduction (-1.96 [-2.81 to -1.10]; N=1745) in the Functional Assessment of Cancer Therapy - Endocrine Symptoms. Cancer-related distress was unchanged or decreased in 5 of 5 studies after risk-reducing mastectomy (N=365) and 8 of 10 studies after risk-reducing salpingo-oophorectomy (N=1223). Risk-reducing early salpingectomy and delayed oophorectomy (2 studies, N=413) led to better sexual function and menopause-specific quality of life. CONCLUSION Risk-reducing surgery may be associated with quality of life outcomes. Risk-reducing mastectomy and risk-reducing salpingo-oophorectomy reduce cancer-related distress, and do not affect health-related quality of life. Women and clinicians should be aware of body image problems after risk-reducing mastectomy, and of sexual dysfunction and menopause symptoms after risk-reducing salpingo-oophorectomy. Risk-reducing early salpingectomy and delayed oophorectomy may be a promising alternative to mitigate quality of life-related risks of risk-reducing salpingo-oophorectomy.
Collapse
Affiliation(s)
- Xia Wei
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom; Wolfson Institute of Population Health, Cancer Research UK Barts Centre, Queen Mary University of London, London, United Kingdom
| | - Samuel Oxley
- Wolfson Institute of Population Health, Cancer Research UK Barts Centre, Queen Mary University of London, London, United Kingdom; Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
| | - Michail Sideris
- Wolfson Institute of Population Health, Cancer Research UK Barts Centre, Queen Mary University of London, London, United Kingdom; Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
| | - Ashwin Kalra
- Wolfson Institute of Population Health, Cancer Research UK Barts Centre, Queen Mary University of London, London, United Kingdom; Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
| | - Adam Brentnall
- Wolfson Institute of Population Health, Cancer Research UK Barts Centre, Queen Mary University of London, London, United Kingdom
| | - Li Sun
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom; Wolfson Institute of Population Health, Cancer Research UK Barts Centre, Queen Mary University of London, London, United Kingdom
| | - Li Yang
- School of Public Health, Peking University, Beijing, China
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ranjit Manchanda
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom; Wolfson Institute of Population Health, Cancer Research UK Barts Centre, Queen Mary University of London, London, United Kingdom; Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom; Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, Faculty of Population Health Sciences, University College London, London, United Kingdom; Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.
| |
Collapse
|
7
|
Orji P, Sun H, Isali I, Bell S, Zaorsky N, Mishra K, Gupta S, Correa A, Smaldone M, Calaway A, Viterbo R, Bukavina L. Female sexual function evaluation and intraoperative vaginal reconstruction in bladder cancer. World J Urol 2023; 41:1751-1762. [PMID: 37419972 DOI: 10.1007/s00345-023-04502-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/12/2023] [Indexed: 07/09/2023] Open
Abstract
RC significantly negatively impacts sexual function (SF) in both men and women. While significant research resources have been allocated to examine the deleterious effects of post prostatectomy erectile dysfunction, little attention has been directed towards female sexual function and organ preservation post cystectomy. These academic shortcomings often result in poor provider awareness and inadequate preoperative assessment. As such, it is crucial for all providers involved in female RC care to understand the necessary and available tools for preoperative evaluation, in addition to the anatomic and reconstructive techniques. This review aims to summarize the current preoperative evaluation and available tools of SF assessment and describe in detail the varying operative techniques in the preservation or restoration of SF in women after RC. The review explores the intricacies of preoperative evaluation tools, and intraoperative techniques for organ- and nerve-sparing during radical cystectomy in females. Particular emphasis on vaginal reconstruction after partial or complete resection is provided, including split-thickness skin (STF) graft vaginoplasy, pedicled flaps, myocutaneous flaps and use of bowel segments. In conclusion, this narrative review highlights the importance of understanding anatomic considerations and nerve-sparing strategies in promoting postoperative SF and quality of life. Furthermore, the review describes the advantages and limitations of each organ- and nerve-sparing technique and their impact on sexual function and overall well-being.
Collapse
Affiliation(s)
- Peace Orji
- Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Helen Sun
- Case Western Reserve School of Medicine, Cleveland, OH, USA
- Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Ilaha Isali
- Case Western Reserve School of Medicine, Cleveland, OH, USA
- Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Spencer Bell
- Department of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Nicholas Zaorsky
- Case Western Reserve School of Medicine, Cleveland, OH, USA
- Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Kirtishri Mishra
- Case Western Reserve School of Medicine, Cleveland, OH, USA
- Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Shubham Gupta
- Case Western Reserve School of Medicine, Cleveland, OH, USA
- Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Andres Correa
- Department of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Marc Smaldone
- Department of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Adam Calaway
- Case Western Reserve School of Medicine, Cleveland, OH, USA
- Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Rosalia Viterbo
- Department of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Laura Bukavina
- Department of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
- Department of Urologic Oncology, Fox Chase Cancer Center, Temple Health Medical Center, Philadelphia, PA, 19111, USA.
| |
Collapse
|
8
|
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.
Collapse
|
9
|
Lee A, Mavaddat N, Cunningham A, Carver T, Ficorella L, Archer S, Walter FM, Tischkowitz M, Roberts J, Usher-Smith J, Simard J, Schmidt MK, Devilee P, Zadnik V, Jürgens H, Mouret-Fourme E, De Pauw A, Rookus M, Mooij TM, Pharoah PP, Easton DF, Antoniou AC. Enhancing the BOADICEA cancer risk prediction model to incorporate new data on RAD51C, RAD51D, BARD1 updates to tumour pathology and cancer incidence. J Med Genet 2022; 59:1206-1218. [PMID: 36162851 PMCID: PMC9691826 DOI: 10.1136/jmedgenet-2022-108471] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/23/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND BOADICEA (Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm) for breast cancer and the epithelial tubo-ovarian cancer (EOC) models included in the CanRisk tool (www.canrisk.org) provide future cancer risks based on pathogenic variants in cancer-susceptibility genes, polygenic risk scores, breast density, questionnaire-based risk factors and family history. Here, we extend the models to include the effects of pathogenic variants in recently established breast cancer and EOC susceptibility genes, up-to-date age-specific pathology distributions and continuous risk factors. METHODS BOADICEA was extended to further incorporate the associations of pathogenic variants in BARD1, RAD51C and RAD51D with breast cancer risk. The EOC model was extended to include the association of PALB2 pathogenic variants with EOC risk. Age-specific distributions of oestrogen-receptor-negative and triple-negative breast cancer status for pathogenic variant carriers in these genes and CHEK2 and ATM were also incorporated. A novel method to include continuous risk factors was developed, exemplified by including adult height as continuous. RESULTS BARD1, RAD51C and RAD51D explain 0.31% of the breast cancer polygenic variance. When incorporated into the multifactorial model, 34%-44% of these carriers would be reclassified to the near-population and 15%-22% to the high-risk categories based on the UK National Institute for Health and Care Excellence guidelines. Under the EOC multifactorial model, 62%, 35% and 3% of PALB2 carriers have lifetime EOC risks of <5%, 5%-10% and >10%, respectively. Including height as continuous, increased the breast cancer relative risk variance from 0.002 to 0.010. CONCLUSIONS These extensions will allow for better personalised risks for BARD1, RAD51C, RAD51D and PALB2 pathogenic variant carriers and more informed choices on screening, prevention, risk factor modification or other risk-reducing options.
Collapse
Affiliation(s)
- Andrew Lee
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Nasim Mavaddat
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Alex Cunningham
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Tim Carver
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lorenzo Ficorella
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fiona M Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Marc Tischkowitz
- Department of Medical Genetics and National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Jonathan Roberts
- Department of Medical Genetics and National Institute for Health Research, Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Juliet Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jacques Simard
- Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Université Laval, Quebec, Quebec, Canada
| | - Marjanka K Schmidt
- Division of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Peter Devilee
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Vesna Zadnik
- Epidemiology and Cancer Registry, Institute of Oncology, Ljubljana, Slovenia
| | - Hannes Jürgens
- Clinic of Hematology and Oncology, Tartu University Hospital, Tartu, Estonia
| | | | | | - Matti Rookus
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thea M Mooij
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Paul Pd Pharoah
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Douglas F Easton
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Antonis C Antoniou
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| |
Collapse
|
10
|
Lee A, Yang X, Tyrer J, Gentry-Maharaj A, Ryan A, Mavaddat N, Cunningham AP, Carver T, Archer S, Leslie G, Kalsi J, Gaba F, Manchanda R, Gayther S, Ramus SJ, Walter FM, Tischkowitz M, Jacobs I, Menon U, Easton DF, Pharoah P, Antoniou AC. Comprehensive epithelial tubo-ovarian cancer risk prediction model incorporating genetic and epidemiological risk factors. J Med Genet 2022; 59:632-643. [PMID: 34844974 PMCID: PMC9252860 DOI: 10.1136/jmedgenet-2021-107904] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/18/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Epithelial tubo-ovarian cancer (EOC) has high mortality partly due to late diagnosis. Prevention is available but may be associated with adverse effects. A multifactorial risk model based on known genetic and epidemiological risk factors (RFs) for EOC can help identify women at higher risk who could benefit from targeted screening and prevention. METHODS We developed a multifactorial EOC risk model for women of European ancestry incorporating the effects of pathogenic variants (PVs) in BRCA1, BRCA2, RAD51C, RAD51D and BRIP1, a Polygenic Risk Score (PRS) of arbitrary size, the effects of RFs and explicit family history (FH) using a synthetic model approach. The PRS, PV and RFs were assumed to act multiplicatively. RESULTS Based on a currently available PRS for EOC that explains 5% of the EOC polygenic variance, the estimated lifetime risks under the multifactorial model in the general population vary from 0.5% to 4.6% for the first to 99th percentiles of the EOC risk distribution. The corresponding range for women with an affected first-degree relative is 1.9%-10.3%. Based on the combined risk distribution, 33% of RAD51D PV carriers are expected to have a lifetime EOC risk of less than 10%. RFs provided the widest distribution, followed by the PRS. In an independent partial model validation, absolute and relative 5-year risks were well calibrated in quintiles of predicted risk. CONCLUSION This multifactorial risk model can facilitate stratification, in particular among women with FH of cancer and/or moderate-risk and high-risk PVs. The model is available via the CanRisk Tool (www.canrisk.org).
Collapse
Affiliation(s)
- Andrew Lee
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Xin Yang
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jonathan Tyrer
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Aleksandra Gentry-Maharaj
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Andy Ryan
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Nasim Mavaddat
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Alex P Cunningham
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Tim Carver
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Goska Leslie
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jatinder Kalsi
- Department of Women's Cancer, University College London Institute for Women's Health, London, UK
- Department of Epidemiology and Public Health, University College London Research, London, UK
| | - Faiza Gaba
- CRUK Barts Cancer Centre, Wolfson Institute of Preventive Medicine, London, UK
| | - Ranjit Manchanda
- CRUK Barts Cancer Centre, Wolfson Institute of Preventive Medicine, London, UK
- Department of Gynaecological Oncology, Barts Health NHS Trust, London, UK
- Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Simon Gayther
- Center for Bioinformatics and Functional Genomics, Cedars-Sinai Medical Center Samuel Oschin Comprehensive Cancer Institute, Los Angeles, California, USA
| | - Susan J Ramus
- University of New South Wales, School of Women's and Children's Health, Randwick, New South Wales, Australia
- Adult Cancer Program, Lowy Cancer Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Marc Tischkowitz
- Department of Medical Genetics, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Ian Jacobs
- Department of Women's Cancer, University College London Institute for Women's Health, London, UK
- University of New South Wales, School of Women's and Children's Health, Randwick, New South Wales, Australia
| | - Usha Menon
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Douglas F Easton
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Paul Pharoah
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Antonis C Antoniou
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| |
Collapse
|
11
|
Gaba F, Oxley S, Liu X, Yang X, Chandrasekaran D, Kalsi J, Antoniou A, Side L, Sanderson S, Waller J, Ahmed M, Wallace A, Wallis Y, Menon U, Jacobs I, Legood R, Marks D, Manchanda R. Unselected Population Genetic Testing for Personalised Ovarian Cancer Risk Prediction: A Qualitative Study Using Semi-Structured Interviews. Diagnostics (Basel) 2022; 12:1028. [PMID: 35626184 PMCID: PMC9139231 DOI: 10.3390/diagnostics12051028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/11/2022] [Accepted: 04/14/2022] [Indexed: 12/24/2022] Open
Abstract
Unselected population-based personalised ovarian cancer (OC) risk assessments combining genetic, epidemiological and hormonal data have not previously been undertaken. We aimed to understand the attitudes, experiences and impact on the emotional well-being of women from the general population who underwent unselected population genetic testing (PGT) for personalised OC risk prediction and who received low-risk (<5% lifetime risk) results. This qualitative study was set within recruitment to a pilot PGT study using an OC risk tool and telephone helpline. OC-unaffected women ≥ 18 years and with no prior OC gene testing were ascertained through primary care in London. In-depth, semi-structured and 1:1 interviews were conducted until informational saturation was reached following nine interviews. Six interconnected themes emerged: health beliefs; decision making; factors influencing acceptability; effect on well-being; results communication; satisfaction. Satisfaction with testing was high and none expressed regret. All felt the telephone helpline was helpful and should remain optional. Delivery of low-risk results reduced anxiety. However, care must be taken to emphasise that low risk does not equal no risk. The main facilitators were ease of testing, learning about children’s risk and a desire to prevent disease. Barriers included change in family dynamics, insurance, stigmatisation and personality traits associated with stress/worry. PGT for personalised OC risk prediction in women in the general population had high acceptability/satisfaction and reduced anxiety in low-risk individuals. Facilitators/barriers observed were similar to those reported with genetic testing from high-risk cancer clinics and unselected PGT in the Jewish population.
Collapse
Affiliation(s)
- Faiza Gaba
- Wolfson Institute of Population Health, Barts CRUK Centre, Queen Mary University of London, Old Anatomy Building, Charterhouse Square, London EC1M 6BQ, UK; (F.G.); (S.O.); (X.L.); (D.C.)
- Department of Gynaecological Oncology, St Bartholomew’s Hospital, London EC1A 7BE, UK
| | - Samuel Oxley
- Wolfson Institute of Population Health, Barts CRUK Centre, Queen Mary University of London, Old Anatomy Building, Charterhouse Square, London EC1M 6BQ, UK; (F.G.); (S.O.); (X.L.); (D.C.)
- Department of Gynaecological Oncology, St Bartholomew’s Hospital, London EC1A 7BE, UK
| | - Xinting Liu
- Wolfson Institute of Population Health, Barts CRUK Centre, Queen Mary University of London, Old Anatomy Building, Charterhouse Square, London EC1M 6BQ, UK; (F.G.); (S.O.); (X.L.); (D.C.)
| | - Xin Yang
- Strangeways Research Laboratory, Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, The University of Cambridge, Cambridge CB1 8RN, UK; (X.Y.); (A.A.)
| | - Dhivya Chandrasekaran
- Wolfson Institute of Population Health, Barts CRUK Centre, Queen Mary University of London, Old Anatomy Building, Charterhouse Square, London EC1M 6BQ, UK; (F.G.); (S.O.); (X.L.); (D.C.)
- Department of Gynaecological Oncology, St Bartholomew’s Hospital, London EC1A 7BE, UK
| | - Jatinderpal Kalsi
- Department of Women’s Cancer, University College London, Gower St, Bloomsbury, London WC1E 6BT, UK;
| | - Antonis Antoniou
- Strangeways Research Laboratory, Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, The University of Cambridge, Cambridge CB1 8RN, UK; (X.Y.); (A.A.)
| | - Lucy Side
- Department of Clinical Genetics, University Hospital Southampton NHS Foundation Trust, Tremona Rd, Southampton SO16 6YD, UK;
| | - Saskia Sanderson
- Early Disease Detection Research Project UK (EDDRP UK), 2 Redman Place, London E20 1JQ, UK;
| | - Jo Waller
- Cancer Prevention Group, King’s College London, Great Maze Pond, London SE1 9RT, UK;
| | - Munaza Ahmed
- North East Thames Regional Genetics Unit, Department Clinical Genetics, Great Ormond Street Hospital, London WC1N 3JH, UK;
| | - Andrew Wallace
- Manchester Centre for Genomic Medicine, 6th Floor Saint Marys Hospital, Oxford Rd, Manchester M13 9WL, UK;
| | - Yvonne Wallis
- West Midlands Regional Genetics Laboratory, Birmingham Women’s NHS Foundation Trust, Birmingham B15 2TG, UK;
| | - Usha Menon
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, 90 High Holborn, London WC1V 6LJ, UK;
| | - Ian Jacobs
- Department of Women’s Health, University of New South Wales, Sydney 2052, Australia;
| | - Rosa Legood
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK; (R.L.); (D.M.)
| | - Dalya Marks
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK; (R.L.); (D.M.)
| | - Ranjit Manchanda
- Wolfson Institute of Population Health, Barts CRUK Centre, Queen Mary University of London, Old Anatomy Building, Charterhouse Square, London EC1M 6BQ, UK; (F.G.); (S.O.); (X.L.); (D.C.)
- Department of Gynaecological Oncology, St Bartholomew’s Hospital, London EC1A 7BE, UK
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, 90 High Holborn, London WC1V 6LJ, UK;
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK; (R.L.); (D.M.)
- Department of Gynaecology, All India Institute of Medical Sciences, New Delhi 110029, India
| |
Collapse
|
12
|
Simões Corrêa Galendi J, Kautz-Freimuth S, Stock S, Müller D. Uptake Rates of Risk-Reducing Surgeries for Women at Increased Risk of Hereditary Breast and Ovarian Cancer Applied to Cost-Effectiveness Analyses: A Scoping Systematic Review. Cancers (Basel) 2022; 14:1786. [PMID: 35406563 PMCID: PMC8997187 DOI: 10.3390/cancers14071786] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 01/09/2023] Open
Abstract
The cost-effectiveness of genetic screen-and-treat strategies for women at increased risk for breast and ovarian cancer often depends on the women's willingness to make use of risk-reducing mastectomy (RRM) or salpingo-oophorectomy (RRSO). To explore the uptake rates of RRM and RRSO applied in health economic modeling studies and the impact of uptake rates on the incremental cost-effectiveness ratios (ICER), we conducted a scoping literature review. In addition, using our own model, we conducted a value of information (VOI) analysis. Among the 19 models included in the review, the uptake rates of RRM ranged from 6% to 47% (RRSO: 10% to 88%). Fifty-seven percent of the models applied retrospective data obtained from registries, hospital records, or questionnaires. According to the models' deterministic sensitivity analyses, there is a clear trend that a lower uptake rate increased the ICER and vice versa. Our VOI analysis showed high decision uncertainty associated with the uptake rates. In the future, uptake rates should be given more attention in the conceptualization of health economic modeling studies. Prospective studies are recommended to reflect regional and national variations in women's preferences for preventive surgery.
Collapse
Affiliation(s)
- Julia Simões Corrêa Galendi
- Institute of Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, 50935 Cologne, Germany; (S.K.-F.); (S.S.)
| | | | | | - Dirk Müller
- Institute of Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, 50935 Cologne, Germany; (S.K.-F.); (S.S.)
| |
Collapse
|
13
|
Manchanda R, Gaba F, Talaulikar V, Pundir J, Gessler S, Davies M, Menon U. Risk-Reducing Salpingo-Oophorectomy and the Use of Hormone Replacement Therapy Below the Age of Natural Menopause: Scientific Impact Paper No. 66 October 2021: Scientific Impact Paper No. 66. BJOG 2022; 129:e16-e34. [PMID: 34672090 PMCID: PMC7614764 DOI: 10.1111/1471-0528.16896] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This paper deals with the use of hormone replacement therapy (HRT) after the removal of fallopian tubes and ovaries to prevent ovarian cancer in premenopausal high risk women. Some women have an alteration in their genetic code, which makes them more likely to develop ovarian cancer. Two well-known genes which can carry an alteration are the BRCA1 and BRCA2 genes. Examples of other genes associated with an increased risk of ovarian cancer include RAD51C, RAD51D, BRIP1, PALB2 and Lynch syndrome genes. Women with a strong family history of ovarian cancer and/or breast cancer, may also be at increased risk of developing ovarian cancer. Women at increased risk can choose to have an operation to remove the fallopian tubes and ovaries, which is the most effective way to prevent ovarian cancer. This is done after a woman has completed her family. However, removal of ovaries causes early menopause and leads to hot flushes, sweats, mood changes and bone thinning. It can also cause memory problems and increases the risk of heart disease. It may reduce libido or impair sexual function. Guidance on how to care for women following preventative surgery who are experiencing early menopause is needed. HRT is usually advisable for women up to 51 years of age (average age of menopause for women in the UK) who are undergoing early menopause and have not had breast cancer, to minimise the health risks linked to early menopause. For women with a womb, HRT should include estrogen coupled with progestogen to protect against thickening of the lining of the womb (called endometrial hyperplasia). For women without a womb, only estrogen is given. Research suggests that, unlike in older women, HRT for women in early menopause does not increase breast cancer risk, including in those who are BRCA1 and BRCA2 carriers and have preventative surgery. For women with a history of receptor-negative breast cancer, the gynaecologist will liaise with an oncology doctor on a case-by-case basis to help to decide if HRT is safe to use. Women with a history of estrogen receptor-positive breast cancer are not normally offered HRT. A range of other therapies can be used if a woman is unable to take HRT. These include behavioural therapy and non-hormonal medicines. However, these are less effective than HRT. Regular exercise, healthy lifestyle and avoiding symptom triggers are also advised. Whether to undergo surgery to reduce risk or not and its timing can be a complex decision-making process. Women need to be carefully counselled on the pros and cons of both preventative surgery and HRT use so they can make informed decisions and choices.
Collapse
|
14
|
Reisel D, Baran C, Manchanda R. Preventive population genomics: The model of BRCA related cancers. ADVANCES IN GENETICS 2021; 108:1-33. [PMID: 34844711 DOI: 10.1016/bs.adgen.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Preventive population genomics offers the prospect of population stratification for targeting screening and prevention and tailoring care to those at greatest risk. Within cancer, this approach is now within reach, given our expanding knowledge of its heritable components, improved ability to predict risk, and increasing availability of effective preventive strategies. Advances in technology and bioinformatics has made population-testing technically feasible. The BRCA model provides 30 years of insight and experience of how to conceive of and construct care and serves as an initial model for preventive population genomics. Population-based BRCA-testing in the Jewish population is feasible, acceptable, reduces anxiety, does not detrimentally affect psychological well-being or quality of life, is cost-effective and is now beginning to be implemented. Population-based BRCA-testing and multigene panel testing in the wider general population is cost-effective for numerous health systems and can save thousands more lives than the current clinical strategy. There is huge potential for using both genetic and non-genetic information in complex risk prediction algorithms to stratify populations for risk adapted screening and prevention. While numerous strides have been made in the last decade several issues need resolving for population genomics to fulfil its promise and potential for maximizing precision prevention. Healthcare systems need to overcome significant challenges associated with developing delivery pathways, infrastructure expansion including laboratory services, clinical workforce training, scaling of management pathways for screening and prevention. Large-scale real world population studies are needed to evaluate context specific population-testing implementation models for cancer risk prediction, screening and prevention.
Collapse
Affiliation(s)
- Dan Reisel
- EGA Institute for Women's Health, University College London, London, United Kingdom
| | - Chawan Baran
- Wolfson Institute of Preventive Medicine, CRUK Barts Centre, Queen Mary University of London, Charterhouse Square, London, United Kingdom
| | - Ranjit Manchanda
- Wolfson Institute of Preventive Medicine, CRUK Barts Centre, Queen Mary University of London, Charterhouse Square, London, United Kingdom; Department of Gynaecological Oncology, St Bartholomew's Hospital, London, United Kingdom; Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, United Kingdom.
| |
Collapse
|
15
|
Yang X, Song H, Leslie G, Engel C, Hahnen E, Auber B, Horváth J, Kast K, Niederacher D, Turnbull C, Houlston R, Hanson H, Loveday C, Dolinsky JS, LaDuca H, Ramus SJ, Menon U, Rosenthal AN, Jacobs I, Gayther SA, Dicks E, Nevanlinna H, Aittomäki K, Pelttari LM, Ehrencrona H, Borg Å, Kvist A, Rivera B, Hansen TVO, Djursby M, Lee A, Dennis J, Bowtell DD, Traficante N, Diez O, Balmaña J, Gruber SB, Chenevix-Trench G, Investigators KC, Jensen A, Kjær SK, Høgdall E, Castéra L, Garber J, Janavicius R, Osorio A, Golmard L, Vega A, Couch FJ, Robson M, Gronwald J, Domchek SM, Culver JO, de la Hoya M, Easton DF, Foulkes WD, Tischkowitz M, Meindl A, Schmutzler RK, Pharoah PDP, Antoniou AC. Ovarian and Breast Cancer Risks Associated With Pathogenic Variants in RAD51C and RAD51D. J Natl Cancer Inst 2020; 112:1242-1250. [PMID: 32107557 PMCID: PMC7735771 DOI: 10.1093/jnci/djaa030] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/07/2020] [Accepted: 02/25/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The purpose of this study was to estimate precise age-specific tubo-ovarian carcinoma (TOC) and breast cancer (BC) risks for carriers of pathogenic variants in RAD51C and RAD51D. METHODS We analyzed data from 6178 families, 125 with pathogenic variants in RAD51C, and 6690 families, 60 with pathogenic variants in RAD51D. TOC and BC relative and cumulative risks were estimated using complex segregation analysis to model the cancer inheritance patterns in families while adjusting for the mode of ascertainment of each family. All statistical tests were two-sided. RESULTS Pathogenic variants in both RAD51C and RAD51D were associated with TOC (RAD51C: relative risk [RR] = 7.55, 95% confidence interval [CI] = 5.60 to 10.19; P = 5 × 10-40; RAD51D: RR = 7.60, 95% CI = 5.61 to 10.30; P = 5 × 10-39) and BC (RAD51C: RR = 1.99, 95% CI = 1.39 to 2.85; P = 1.55 × 10-4; RAD51D: RR = 1.83, 95% CI = 1.24 to 2.72; P = .002). For both RAD51C and RAD51D, there was a suggestion that the TOC relative risks increased with age until around age 60 years and decreased thereafter. The estimated cumulative risks of developing TOC to age 80 years were 11% (95% CI = 6% to 21%) for RAD51C and 13% (95% CI = 7% to 23%) for RAD51D pathogenic variant carriers. The estimated cumulative risks of developing BC to 80 years were 21% (95% CI = 15% to 29%) for RAD51C and 20% (95% CI = 14% to 28%) for RAD51D pathogenic variant carriers. Both TOC and BC risks for RAD51C and RAD51D pathogenic variant carriers varied by cancer family history and could be as high as 32-36% for TOC, for carriers with two first-degree relatives diagnosed with TOC, or 44-46% for BC, for carriers with two first-degree relatives diagnosed with BC. CONCLUSIONS These estimates will facilitate the genetic counseling of RAD51C and RAD51D pathogenic variant carriers and justify the incorporation of RAD51C and RAD51D into cancer risk prediction models.
Collapse
Affiliation(s)
- Xin Yang
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Honglin Song
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
- Department of Oncology, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Goska Leslie
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Christoph Engel
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Eric Hahnen
- Faculty of Medicine and University Hospital Cologne, Center for Familial Breast and Ovarian Cancer, University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology, University of Cologne, Cologne, Germany
| | - Bernd Auber
- Institute of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Judit Horváth
- Institute of Human Genetics, University of Münster, Münster, Germany
| | - Karin Kast
- Department of Gynecology and Obstetrics, Medical Faculty and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT), Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
- German Cancer Consortium (DKTK), Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dieter Niederacher
- Department of Gynecology and Obstetrics, Heinrich-Heine University Düsseldorf, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Clare Turnbull
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Richard Houlston
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Helen Hanson
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Chey Loveday
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | | | | | - Susan J Ramus
- School of Women’s and Children’s Health, Faculty of Medicine, University of NSW Sydney, Sydney, New South Wales, Australia
- Garvan Institute of Medical Research, The Kinghorn Cancer Centre, Sydney, New South Wales, Australia
- Adult Cancer Program, Lowy Cancer Research Centre, University of NSW Sydney, Sydney, New South Wales, Australia
| | - Usha Menon
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Adam N Rosenthal
- Women’s Cancer, Institute for Women’s Health, University College London, London, UK
| | - Ian Jacobs
- Women’s Cancer, Institute for Women’s Health, University College London, London, UK
- University of New South Wales, Sydney, New South Wales, Australia
- University of Manchester, Manchester, UK
| | - Simon A Gayther
- Center for Bioinformatics and Functional Genomics and the Cedars Sinai Genomics Core, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ed Dicks
- Department of Oncology, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Heli Nevanlinna
- Department of Obstetrics and Gynecology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Kristiina Aittomäki
- Department of Clinical Genetics, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Liisa M Pelttari
- Department of Obstetrics and Gynecology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Hans Ehrencrona
- Department of Clinical Genetics and Pathology, Laboratory Medicine, Office for Medical Services, Region Skåne, Lund, Sweden
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Åke Borg
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Anders Kvist
- Division of Oncology and Pathology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Barbara Rivera
- Gerald Bronfman Dept Oncology, Jewish General Hospital, McGill University and Lady Davis Institute, Montréal, QC, Canada
- Program in Molecular Mechanisms and Experimental Therapy in Oncology (Oncobell), IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Thomas V O Hansen
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Genetics Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Malene Djursby
- Department of Clinical Genetics Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andrew Lee
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Joe Dennis
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - David D Bowtell
- Peter MacCallum Cancer Center, Melbourne, Victoria, Australia
- Sir Peter MacCallum, Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Nadia Traficante
- Peter MacCallum Cancer Center, Melbourne, Victoria, Australia
- Sir Peter MacCallum, Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Orland Diez
- Oncogenetics Group, Vall dHebron Institute of Oncology, Barcelona, Spain
- Clinical and Molecular Genetics Area, University Hospital Vall dHebron, Barcelona, Spain
| | - Judith Balmaña
- Hereditary Cancer Genetics Group, Vall d’Hebron Institute of Oncology, Barcelona, Spain
- Department of Medical Oncology, University Hospital of Vall d’Hebron, Barcelona, Spain
| | - Stephen B Gruber
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Georgia Chenevix-Trench
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | | | - Allan Jensen
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Susanne K Kjær
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Gynaecology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Estrid Høgdall
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Pathology, Molecular Unit, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Laurent Castéra
- Department of Cancer Biology and Genetics, Normandy Centre for Genomic and Personalized Medicine, François Baclesse Center, Inserm U1245, Caen, France
| | - Judy Garber
- Cancer Risk and Prevention Clinic, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ramunas Janavicius
- Department of Molecular and Regenerative Medicine, Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital Santariskiu Clinics, Vilnius, Lithuania
- State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
| | - Ana Osorio
- Centro de Investigación en Red de Enfermedades Raras, Madrid, Spain
- Human Cancer Genetics Programme, Spanish National Cancer Research Centre, Madrid, Spain
| | - Lisa Golmard
- Institut Curie, Paris Sciences Lettres Research University, Service de Génétique, Paris, France
| | - Ana Vega
- Centro de Investigación en Red de Enfermedades Raras, Madrid, Spain
- Fundación Pública Galega de Medicina Xenómica, Santiago de Compostela, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela, Complejo Hospitalario Universitario de Santiago, SERGAS, Santiago de Compostela, Spain
| | - Fergus J Couch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Mark Robson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, Clinical Genetics Service, New York, NY, USA
| | - Jacek Gronwald
- Department of Genetics and Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Susan M Domchek
- Basser Center for BRCA, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Julie O Culver
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Miguel de la Hoya
- Molecular Oncology Laboratory CIBERONC, Hospital Clinico San Carlos, IdISSC (Instituto de Investigación Sanitaria del Hospital Clínico San Carlos), Madrid, Spain
| | - Douglas F Easton
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
- Department of Oncology, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - William D Foulkes
- Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology, University of Cologne, Cologne, Germany
- Department of Gynecology and Obstetrics, Medical Faculty and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marc Tischkowitz
- Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology, University of Cologne, Cologne, Germany
- National Center for Tumor Diseases (NCT), Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Alfons Meindl
- Department of Gynecology and Obstetrics, University of Munich, Campus Großhadern, Munich, Germany
| | - Rita K Schmutzler
- Faculty of Medicine and University Hospital Cologne, Center for Familial Breast and Ovarian Cancer, University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology, University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Center for Molecular Medicine Cologne, University of Cologne, Cologne, Germany
| | - Paul D P Pharoah
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
- Department of Oncology, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Antonis C Antoniou
- Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| |
Collapse
|
16
|
Gallagher A, Waller J, Manchanda R, Jacobs I, Sanderson S. Women's Intentions to Engage in Risk-Reducing Behaviours after Receiving Personal Ovarian Cancer Risk Information: An Experimental Survey Study. Cancers (Basel) 2020; 12:cancers12123543. [PMID: 33260928 PMCID: PMC7760356 DOI: 10.3390/cancers12123543] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/11/2020] [Accepted: 11/24/2020] [Indexed: 12/02/2022] Open
Abstract
Simple Summary Risk stratification using genetic testing to identify women at increased risk of ovarian cancer may increase the number of patients to whom risk-reducing surgery (e.g., salpingo-oophorectomy) may be offered. However, little is known about public acceptability of such approaches. Our online experimental survey aimed to explore whether women aged 45–75 in the general population are willing to undergo ovarian cancer risk assessment, including genetic testing, and whether women’s potential acceptance of risk-reducing surgery differs depending on their estimated risk. We looked at whether psychological and cognitive factors mediated women’s decision-making. The majority of participants would be interested in having genetic testing. In response to our hypothetical scenarios, a substantial proportion of participants were open to the idea of surgery to reduce risk of ovarian cancer, even if their absolute lifetime risk is only increased from 2% to 5 or 10%. Abstract Risk stratification using genetic and/or other types of information could identify women at increased ovarian cancer risk. The aim of this study was to examine women’s potential reactions to ovarian cancer risk stratification. A total of 1017 women aged 45–75 years took part in an online experimental survey. Women were randomly assigned to one of three experimental conditions describing hypothetical personal results from ovarian cancer risk stratification, and asked to imagine they had received one of three results: (a) 5% lifetime risk due to single nucleotide polymorphisms (SNPs) and lifestyle factors; (b) 10% lifetime risk due to SNPs and lifestyle factors; (c) 10% lifetime risk due to a single rare mutation in a gene. Results: 83% of women indicated interest in having ovarian cancer risk assessment. After receiving their hypothetical risk estimates, 29% of women stated they would have risk-reducing surgery. Choosing risk-reducing surgery over other behavioural responses was associated with having higher surgery self-efficacy and perceived response-efficacy, but not with perceptions of disease threat, i.e., perceived risk or severity, or with experimental condition. A substantial proportion of women age 45–75 years may be open to the idea of surgery to reduce risk of ovarian cancer, even if their absolute lifetime risk is only increased to as little as 5 or 10%.
Collapse
Affiliation(s)
- Ailish Gallagher
- Research Department of Behavioural Science and Health, University College London, Gower Street, London WC1E 6BT, UK;
| | - Jo Waller
- Cancer Prevention Group, School of Cancer & Pharmaceutical Sciences, King’s College London, Guy’s Hospital, Great Maze Pond, London SE1 9RT, UK;
| | - Ranjit Manchanda
- Wolfson Institute of Preventive Medicine, Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK;
- Department of Gynaecological Oncology, Barts Health NHS Trust, London EC1A 7BE, UK
| | - Ian Jacobs
- Department of Women’s Health, University of New South Wales, Australia, Level 1, Chancellery Building, Sydney 2052, Australia;
| | - Saskia Sanderson
- Research Department of Behavioural Science and Health, University College London, Gower Street, London WC1E 6BT, UK;
- Early Disease Detection Research Project UK (EDDRP UK), 2 Redman Place, London E20 1JQ, UK
- Correspondence:
| |
Collapse
|
17
|
Kvaskoff M, Mahamat-Saleh Y, Farland LV, Shigesi N, Terry KL, Harris HR, Roman H, Becker CM, As-Sanie S, Zondervan KT, Horne AW, Missmer SA. Endometriosis and cancer: a systematic review and meta-analysis. Hum Reprod Update 2020; 27:393-420. [PMID: 33202017 DOI: 10.1093/humupd/dmaa045] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/16/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Endometriosis is an often chronic, inflammatory gynaecologic condition affecting 190 million women worldwide. Studies have reported an elevated cancer risk among patients with endometriosis. However, prior research has included methodologic issues that impede valid and robust interpretation. OBJECTIVE AND RATIONALE We conducted a meta-analysis of studies investigating the association between endometriosis and cancer risk and analysed the results by methodologic characteristics. We discuss the implications of cancer screening in patients and management challenges faced by clinicians. SEARCH METHODS We searched PubMed and Embase databases for eligible studies from inception through 24 October 2019. We included cohort and case-control studies examining the association between endometriosis and cancer risk; cross-sectional studies and case reports were excluded. Publications had to present risk/rate/odds estimates with 95% CI. Random effects meta-analysis was used to estimate summary relative risks (SRR) and CIs. Heterogeneity across studies was assessed by the Q test and I2 statistics, and publication bias using Egger's and Begg's tests. Risk of bias and quality of the included studies were assessed using the risk of bias in non-randomized studies of interventions (ROBINS-I) tool. OUTCOMES Forty-nine population-based case-control and cohort studies were included. Twenty-six studies were scored as having a 'serious'/'critical' risk of bias, and the remaining 23 'low'/'moderate'. Cancer-specific analyses showed a positive association between endometriosis and ovarian cancer risk (SRR = 1.93, 95% CI = 1.68-2.22; n = 24 studies) that was strongest for clear cell (SRR = 3.44, 95% CI = 2.82-4.42; n = 5 studies) and endometrioid (SRR = 2.33, 95% CI = 1.82-2.98; n = 5 studies) histotypes (Pheterogeneity < 0.0001), although with significant evidence of both heterogeneity across studies and publication bias (Egger's and Begg's P-values < 0.01). A robust association was observed between endometriosis and thyroid cancer (SRR = 1.39, 95% CI =1.24-1.57; n = 5 studies), a very small association with breast cancer (SRR = 1.04, 95% CI =1.00-1.09; n = 20 studies) and no association with colorectal cancer (SRR = 1.00, 95% CI =0.87-1.16; n = 5 studies). The association with endometrial cancer was not statistically significant (SRR = 1.23, 95% CI =0.97-1.57; n = 17 studies) overall and wholly null when restricted to prospective cohort studies (SRR = 0.99, 95% CI =0.72-1.37; n = 5 studies). The association with cutaneous melanoma was also non-significant (SRR = 1.17, 95% CI =0.97-1.41; n = 7 studies) but increased in magnitude and was statistically significant when restricted to studies with low/moderate risk of bias (SRR = 1.71, 95% CI = 1.24-2.36, n = 2 studies). The most robust finding both in terms of statistical significance and magnitude of effect was an inverse association with cervical cancer (SRR = 0.68, 95% CI =0.56-0.82; n = 4 studies); however, this result has a high potential to reflect heightened access to detection of dysplasia for women who reached an endometriosis diagnosis and is thus likely not causal. Several additional cancer types were explored based on <4 studies. WIDER IMPLICATIONS Endometriosis was associated with a higher risk of ovarian and thyroid, and minimally (only 4% greater risk) with breast cancer, and with a lower risk of cervical cancer. However, this meta-analysis confirms that: a majority of studies had severe/critical risk of bias; there is impactful heterogeneity across studies-and for ovarian cancer, publication bias; and causal inference requires temporality, which in many studies was not considered. We discuss the implications of these potential associations from the perspectives of patients with endometriosis, clinicians involved in their care, and scientists investigating their long-term health risks.
Collapse
Affiliation(s)
- Marina Kvaskoff
- CESP, Fac. de médecine - Univ. Paris-Sud, Fac. de médecine - UVSQ, INSERM, Université Paris-Saclay, Villejuif 94805, France.,Gustave Roussy, Villejuif F-94805, France
| | - Yahya Mahamat-Saleh
- CESP, Fac. de médecine - Univ. Paris-Sud, Fac. de médecine - UVSQ, INSERM, Université Paris-Saclay, Villejuif 94805, France.,Gustave Roussy, Villejuif F-94805, France
| | - Leslie V Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Nina Shigesi
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Kathryn L Terry
- Obstetrics and Gynecology Epidemiology Center, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Holly R Harris
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Horace Roman
- Endometriosis Centre, Tivoli-Ducos Clinic, Bordeaux, France.,Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian M Becker
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Sawsan As-Sanie
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Krina T Zondervan
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK.,Wellcome Centre for Human Genetics, University of Oxford, UK
| | - Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Stacey A Missmer
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
| |
Collapse
|
18
|
Surveillance in Older Women With Incidental Ovarian Cysts: Maximal Projected Benefits by Age and Comorbidity Level. J Am Coll Radiol 2020; 18:10-18. [PMID: 33096089 DOI: 10.1016/j.jacr.2020.09.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/12/2020] [Accepted: 09/14/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE The aim of this study was to estimate effects on life expectancy (LE) of imaging-based ovarian surveillance after detection of incidental postmenopausal ovarian cysts, under different assumptions of patient age, comorbidity level, and cancer risk and detection. METHODS A decision-analytic Markov model was developed to estimate LE benefits. Hypothetical cohorts of postmenopausal women with simple ovarian cysts were evaluated, with varied age (66-80 years) and comorbidity level (none, mild, moderate, severe). For each cohort, imaging "follow-up" (2 years) and "no-follow-up" strategies were compared. Consistent with current evidence, increased cancer risk in patients with cysts was not assumed; however, incident ovarian cancers could be detected during follow-up. To estimate theoretical maximal LE gains from follow-up, perfect ovarian cancer detection and treatment during follow-up were assumed. This and other key assumptions were varied in sensitivity analysis. RESULTS Projected LE gains from follow-up were limited. For 66-, 70-, 75-, and 80-year-old women with no comorbidities, LE gains were 5.1, 5.1, 4.5, and 3.7 days; with severe comorbidities, they were 3.5, 3.2, 2.7, and 2.1 days. With sensitivity of 50% for cancer detection, they were 3.7 days for 66-year-old women with no comorbidities and 1.3 days for 80-year-old women with severe comorbidities. When cancer risk for women with cysts was assumed to be elevated (1.1 times average risk), LE gains increased only modestly (5.6 and 2.3 days for analogous cohorts). CONCLUSIONS Even in the circumstance of perfect ovarian cancer detection and treatment, surveillance of postmenopausal women (≥66 years of age) with simple cysts affords limited benefits, particularly in women with advanced age and comorbidities.
Collapse
|
19
|
Pavanello M, Chan IHY, Ariff A, Pharoah PDP, Gayther SA, Ramus SJ. Rare Germline Genetic Variants and the Risks of Epithelial Ovarian Cancer. Cancers (Basel) 2020; 12:E3046. [PMID: 33086730 PMCID: PMC7589980 DOI: 10.3390/cancers12103046] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 02/06/2023] Open
Abstract
A family history of ovarian or breast cancer is the strongest risk factor for epithelial ovarian cancer (EOC). Germline deleterious variants in the BRCA1 and BRCA2 genes confer EOC risks by age 80, of 44% and 17% respectively. The mismatch repair genes, particularly MSH2 and MSH6, are also EOC susceptibility genes. Several other DNA repair genes, BRIP1, RAD51C, RAD51D, and PALB2, have been identified as moderate risk EOC genes. EOC has five main histotypes; high-grade serous (HGS), low-grade serous (LGS), clear cell (CCC), endometrioid (END), and mucinous (MUC). This review examines the current understanding of the contribution of rare genetic variants to EOC, focussing on providing frequency data for each histotype. We provide an overview of frequency and risk for pathogenic variants in the known susceptibility genes as well as other proposed genes. We also describe the progress to-date to understand the role of missense variants and the different breast and ovarian cancer risks for each gene. Identification of susceptibility genes have clinical impact by reducing disease-associated mortality through improving risk prediction, with the possibility of prevention strategies, and developing new targeted treatments and these clinical implications are also discussed.
Collapse
Affiliation(s)
- Marina Pavanello
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney 2052, Australia; (M.P.); (I.H.C.); (A.A.)
- Adult Cancer Program, Lowy Cancer Research Centre, University of New South Wales, Sydney 2052, Australia
| | - Isaac HY Chan
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney 2052, Australia; (M.P.); (I.H.C.); (A.A.)
| | - Amir Ariff
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney 2052, Australia; (M.P.); (I.H.C.); (A.A.)
- Adult Cancer Program, Lowy Cancer Research Centre, University of New South Wales, Sydney 2052, Australia
| | - Paul DP Pharoah
- Strangeways Research Laboratory, University of Cambridge, Cambridge CB1 8RN, UK;
| | - Simon A. Gayther
- Center for Cancer Prevention and Translational Genomics, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA;
- Applied Genomics, Computation and Translational Core, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Susan J. Ramus
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney 2052, Australia; (M.P.); (I.H.C.); (A.A.)
- Adult Cancer Program, Lowy Cancer Research Centre, University of New South Wales, Sydney 2052, Australia
| |
Collapse
|
20
|
Gaba F, Blyuss O, Chandrasekaran D, Osman M, Goyal S, Gan C, Izatt L, Tripathi V, Esteban I, McNicol L, Ragupathy K, Crawford R, Evans DG, Legood R, Menon U, Manchanda R. Attitudes towards risk-reducing early salpingectomy with delayed oophorectomy for ovarian cancer prevention: a cohort study. BJOG 2020; 128:714-726. [PMID: 32803845 DOI: 10.1111/1471-0528.16424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine risk-reducing early salpingectomy and delayed oophorectomy (RRESDO) acceptability and effect of surgical prevention on menopausal sequelae/satisfaction/regret in women at increased ovarian cancer (OC) risk. DESIGN Multicentre, cohort, questionnaire study (IRSCTN:12310993). SETTING United Kingdom (UK). POPULATION UK women without OC ≥18 years, at increased OC risk, with/without previous RRSO, ascertained through specialist familial cancer/genetic clinics and BRCA support groups. METHODS Participants completed a 39-item questionnaire. Baseline characteristics were described using descriptive statistics. Logistic/linear regression models analysed the impact of variables on RRESDO acceptability and health outcomes. MAIN OUTCOMES RRESDO acceptability, menopausal sequelae, satisfaction/regret. RESULTS In all, 346 of 683 participants underwent risk-reducing salpingo-oophorectomy (RRSO). Of premenopausal women who had not undergone RRSO, 69.1% (181/262) found it acceptable to participate in a research study offering RRESDO. Premenopausal women concerned about sexual dysfunction were more likely to find RRESDO acceptable (odds ratio [OR] = 2.9, 95% CI 1.2-7.7, P = 0.025). Women experiencing sexual dysfunction after premenopausal RRSO were more likely to find RRESDO acceptable in retrospect (OR = 5.3, 95% CI 1.2-27.5, P < 0.031). In all, 88.8% (143/161) premenopausal and 95.2% (80/84) postmenopausal women who underwent RRSO, respectively, were satisfied with their decision, whereas 9.4% (15/160) premenopausal and 1.2% (1/81) postmenopausal women who underwent RRSO regretted their decision. HRT uptake in premenopausal individuals without breast cancer (BC) was 74.1% (80/108). HRT use did not significantly affect satisfaction/regret levels but did reduce symptoms of vaginal dryness (OR = 0.4, 95% CI 0.2-0.9, P = 0.025). CONCLUSION Data show high RRESDO acceptability, particularly in women concerned about sexual dysfunction. Although RRSO satisfaction remains high, regret rates are much higher for premenopausal women than for postmenopausal women. HRT use following premenopausal RRSO does not increase satisfaction but does reduce vaginal dryness. TWEETABLE ABSTRACT RRESDO has high acceptability among premenopausal women at increased ovarian cancer risk, particularly those concerned about sexual dysfunction.
Collapse
Affiliation(s)
- F Gaba
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK.,Department of Gynaecological Oncology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - O Blyuss
- School of Physics, Astronomy and Mathematics, University of Hertfordshire, Hatfield, UK.,Department of Paediatrics and Paediatric Infectious Diseases, Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Applied Mathematics, Lobachevsky State University of Nizhny Novgorod, Nizhny Novgorod, Russia
| | - D Chandrasekaran
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK.,Department of Gynaecological Oncology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - M Osman
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - S Goyal
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - C Gan
- Department of Gynaecological Oncology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - L Izatt
- Department of Clinical Genetics, Guy's Hospital, London, UK
| | - V Tripathi
- Department of Clinical Genetics, Guy's Hospital, London, UK
| | - I Esteban
- Ninewells Hospital, NHS Tayside, Dundee, UK
| | - L McNicol
- Ninewells Hospital, NHS Tayside, Dundee, UK
| | | | - R Crawford
- Department of Gynaecological Oncology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - D G Evans
- Manchester Centre for Genomic Medicine, MAHSC, Division of Evolution and Genomic Sciences, University of Manchester, Manchester, UK
| | - R Legood
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - U Menon
- MRC Clinical Trials Unit, University College London, London, UK
| | - R Manchanda
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK.,Department of Gynaecological Oncology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.,MRC Clinical Trials Unit, University College London, London, UK
| |
Collapse
|
21
|
A model integrating environmental concerns and supply risks for dynamic sustainable supplier selection and order allocation. Soft comput 2020. [DOI: 10.1007/s00500-020-05165-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
22
|
Gaba F, Blyuss O, Liu X, Goyal S, Lahoti N, Chandrasekaran D, Kurzer M, Kalsi J, Sanderson S, Lanceley A, Ahmed M, Side L, Gentry-Maharaj A, Wallis Y, Wallace A, Waller J, Luccarini C, Yang X, Dennis J, Dunning A, Lee A, Antoniou AC, Legood R, Menon U, Jacobs I, Manchanda R. Population Study of Ovarian Cancer Risk Prediction for Targeted Screening and Prevention. Cancers (Basel) 2020; 12:E1241. [PMID: 32429029 PMCID: PMC7281662 DOI: 10.3390/cancers12051241] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/01/2020] [Accepted: 05/06/2020] [Indexed: 02/03/2023] Open
Abstract
Unselected population-based personalised ovarian cancer (OC) risk assessment combining genetic/epidemiology/hormonal data has not previously been undertaken. We aimed to perform a feasibility study of OC risk stratification of general population women using a personalised OC risk tool followed by risk management. Volunteers were recruited through London primary care networks. INCLUSION CRITERIA women ≥18 years. EXCLUSION CRITERIA prior ovarian/tubal/peritoneal cancer, previous genetic testing for OC genes. Participants accessed an online/web-based decision aid along with optional telephone helpline use. Consenting individuals completed risk assessment and underwent genetic testing (BRCA1/BRCA2/RAD51C/RAD51D/BRIP1, OC susceptibility single-nucleotide polymorphisms). A validated OC risk prediction algorithm provided a personalised OC risk estimate using genetic/lifestyle/hormonal OC risk factors. Population genetic testing (PGT)/OC risk stratification uptake/acceptability, satisfaction, decision aid/telephone helpline use, psychological health and quality of life were assessed using validated/customised questionnaires over six months. Linear-mixed models/contrast tests analysed impact on study outcomes. MAIN OUTCOMES feasibility/acceptability, uptake, decision aid/telephone helpline use, satisfaction/regret, and impact on psychological health/quality of life. In total, 123 volunteers (mean age = 48.5 (SD = 15.4) years) used the decision aid, 105 (85%) consented. None fulfilled NHS genetic testing clinical criteria. OC risk stratification revealed 1/103 at ≥10% (high), 0/103 at ≥5%-<10% (intermediate), and 100/103 at <5% (low) lifetime OC risk. Decision aid satisfaction was 92.2%. The telephone helpline use rate was 13% and the questionnaire response rate at six months was 75%. Contrast tests indicated that overall depression (p = 0.30), anxiety (p = 0.10), quality-of-life (p = 0.99), and distress (p = 0.25) levels did not jointly change, while OC worry (p = 0.021) and general cancer risk perception (p = 0.015) decreased over six months. In total, 85.5-98.7% were satisfied with their decision. Findings suggest population-based personalised OC risk stratification is feasible and acceptable, has high satisfaction, reduces cancer worry/risk perception, and does not negatively impact psychological health/quality of life.
Collapse
Affiliation(s)
- Faiza Gaba
- Wolfson Institute of Preventative Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK; (F.G.); (X.L.); (S.G.); (N.L.); (D.C.)
- Department of Gynaecological Oncology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, UK;
| | - Oleg Blyuss
- School of Physics, Astronomy and Mathematics, University of Hertfordshire, College Lane, Hatfield AL10 9AB, UK;
- Department of Paediatrics and Paediatric Infectious Diseases, Sechenov First Moscow State Medical University, Moscow 119146, Russia
- Department of Applied Mathematics, Lobachevsky State University of Nizhny Novgorod, Nizhny Novgorod 603098, Russia
| | - Xinting Liu
- Wolfson Institute of Preventative Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK; (F.G.); (X.L.); (S.G.); (N.L.); (D.C.)
| | - Shivam Goyal
- Wolfson Institute of Preventative Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK; (F.G.); (X.L.); (S.G.); (N.L.); (D.C.)
| | - Nishant Lahoti
- Wolfson Institute of Preventative Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK; (F.G.); (X.L.); (S.G.); (N.L.); (D.C.)
| | - Dhivya Chandrasekaran
- Wolfson Institute of Preventative Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK; (F.G.); (X.L.); (S.G.); (N.L.); (D.C.)
- Department of Gynaecological Oncology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, UK;
| | - Margarida Kurzer
- Department of Gynaecological Oncology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, UK;
| | - Jatinderpal Kalsi
- Department of Women’s Cancer, Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London WC1E 6AU, UK; (J.K.); (A.L.)
| | - Saskia Sanderson
- Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK;
| | - Anne Lanceley
- Department of Women’s Cancer, Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London WC1E 6AU, UK; (J.K.); (A.L.)
| | - Munaza Ahmed
- Department Clinical Genetics, North East Thames Regional Genetics Unit, Great Ormond Street Hospital, London WC1N 3JH, UK;
| | - Lucy Side
- Department of Clinical Genetics, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK;
| | - Aleksandra Gentry-Maharaj
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, 90 High Holborn, London WC1V 6LJ, UK; (A.G.-M.); (U.M.)
| | - Yvonne Wallis
- West Midlands Regional Genetics Laboratory, Birmingham Women’s NHS Foundation Trust, Birmingham B15 2TG, UK;
| | - Andrew Wallace
- Manchester Centre for Genomic Medicine, 6th Floor Saint Marys Hospital, Oxford Rd, Manchester M13 9WL, UK;
| | - Jo Waller
- Cancer Prevention Group, King’s College London, Great Maze Pond, London SE1 9RT, UK;
| | - Craig Luccarini
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Strangeways Laboratory, Worts Causeway, Cambridge CB1 8RN, UK; (C.L.); (X.Y.); (J.D.); (A.D.); (A.L.); (A.C.A.)
| | - Xin Yang
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Strangeways Laboratory, Worts Causeway, Cambridge CB1 8RN, UK; (C.L.); (X.Y.); (J.D.); (A.D.); (A.L.); (A.C.A.)
| | - Joe Dennis
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Strangeways Laboratory, Worts Causeway, Cambridge CB1 8RN, UK; (C.L.); (X.Y.); (J.D.); (A.D.); (A.L.); (A.C.A.)
| | - Alison Dunning
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Strangeways Laboratory, Worts Causeway, Cambridge CB1 8RN, UK; (C.L.); (X.Y.); (J.D.); (A.D.); (A.L.); (A.C.A.)
| | - Andrew Lee
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Strangeways Laboratory, Worts Causeway, Cambridge CB1 8RN, UK; (C.L.); (X.Y.); (J.D.); (A.D.); (A.L.); (A.C.A.)
| | - Antonis C. Antoniou
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Strangeways Laboratory, Worts Causeway, Cambridge CB1 8RN, UK; (C.L.); (X.Y.); (J.D.); (A.D.); (A.L.); (A.C.A.)
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | - Usha Menon
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, 90 High Holborn, London WC1V 6LJ, UK; (A.G.-M.); (U.M.)
| | - Ian Jacobs
- Department of Women’s Health, University of New South Wales, Australia, Level 1, Chancellery Building, Sydney 2052, Australia;
| | - Ranjit Manchanda
- Wolfson Institute of Preventative Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK; (F.G.); (X.L.); (S.G.); (N.L.); (D.C.)
- Department of Gynaecological Oncology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, UK;
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, 90 High Holborn, London WC1V 6LJ, UK; (A.G.-M.); (U.M.)
| |
Collapse
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Manchanda R, Gaba F. A commentary on population genetic testing for primary prevention: changing landscape and the need to change paradigm. BJOG 2019; 126:686-689. [DOI: 10.1111/1471-0528.15657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2019] [Indexed: 12/25/2022]
Affiliation(s)
- R Manchanda
- Barts Cancer Institute Queen Mary University of London London UK
- Department of Gynaecological Oncology St Bartholomew's Hospital London UK
- MRC Clinical Trials Unit at UCL Faculty of Population Health Sciences Institute of Clinical Trials and Methodology University College London London UK
| | - F Gaba
- Barts Cancer Institute Queen Mary University of London London UK
- Department of Gynaecological Oncology St Bartholomew's Hospital London UK
| |
Collapse
|
25
|
Manchanda R, Gaba F. Population Based Testing for Primary Prevention: A Systematic Review. Cancers (Basel) 2018; 10:cancers10110424. [PMID: 30400647 PMCID: PMC6266041 DOI: 10.3390/cancers10110424] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 10/24/2018] [Accepted: 10/31/2018] [Indexed: 12/29/2022] Open
Abstract
The current clinical model for genetic testing is based on clinical-criteria/family-history (FH) and a pre-defined mutation probability threshold. It requires people to develop cancer before identifying unaffected individuals in the family to target prevention. This process is inefficient, resource intensive and misses >50% of individuals or mutation carriers at risk. Population genetic-testing can overcome these limitations. It is technically feasible to test populations on a large scale; genetic-testing costs are falling and acceptability and awareness are rising. MEDLINE, EMBASE, Pubmed, CINAHL and PsychINFO databases were searched using free-text and MeSH terms; retrieved reference lists of publications were screened; additionally, web-based platforms, Google, and clinical-trial registries were searched. Quality of studies was evaluated using appropriate check-lists. A number of studies have evaluated population-based BRCA-testing in the Jewish population. This has been found to be acceptable, feasible, clinically-effective, safe, associated with high satisfaction rates and extremely cost-effective. Data support change in guidelines for population-based BRCA-testing in the Jewish population. Population panel testing for BRCA1/BRCA2/RAD51C/RAD51D/BRIP1/PALB2 gene mutations is the most cost-effective genetic-testing strategy in general-population women and can prevent thousands more breast and ovarian cancers than current clinical-criteria based approaches. A few ongoing studies are evaluating population-based genetic-testing for multiple cancer susceptibility genes in the general population but more implementation studies are needed. A future population-testing programme could also target other chronic diseases.
Collapse
Affiliation(s)
- Ranjit Manchanda
- Barts Cancer Institute, Queen Mary University of London, Old Anatomy Building, Charterhouse Square, London EC1M 6BQ, UK.
- Department of Gynaecological Oncology, St Bartholomew's Hospital, London EC1A 7BE, UK.
- Gynaecological Cancer Research Centre, Department of Women's Cancer, Institute for Women's Health, University College London, 149 Tottenham Court Road, London W1T 7DN, UK.
| | - Faiza Gaba
- Barts Cancer Institute, Queen Mary University of London, Old Anatomy Building, Charterhouse Square, London EC1M 6BQ, UK.
- Department of Gynaecological Oncology, St Bartholomew's Hospital, London EC1A 7BE, UK.
| |
Collapse
|
26
|
Manchanda R, Legood R. Population based germline testing for primary cancer prevention. Oncotarget 2018; 9:33062-33063. [PMID: 30237851 PMCID: PMC6145693 DOI: 10.18632/oncotarget.25995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 08/11/2018] [Indexed: 01/19/2023] Open
Affiliation(s)
- Ranjit Manchanda
- Ranjit Manchanda: Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London, UK; Department of Gynaecological Oncology, St Bartholomew's Hospital, London, UK; Gynaecological Cancer Research Centre, Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
- Rosa Legood: Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rosa Legood
- Ranjit Manchanda: Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London, UK; Department of Gynaecological Oncology, St Bartholomew's Hospital, London, UK; Gynaecological Cancer Research Centre, Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
- Rosa Legood: Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
27
|
Yang X, Leslie G, Gentry-Maharaj A, Ryan A, Intermaggio M, Lee A, Kalsi JK, Tyrer J, Gaba F, Manchanda R, Pharoah PDP, Gayther SA, Ramus SJ, Jacobs I, Menon U, Antoniou AC. Evaluation of polygenic risk scores for ovarian cancer risk prediction in a prospective cohort study. J Med Genet 2018; 55:546-554. [PMID: 29730597 PMCID: PMC6073911 DOI: 10.1136/jmedgenet-2018-105313] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/04/2018] [Accepted: 04/17/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Genome-wide association studies have identified >30 common SNPs associated with epithelial ovarian cancer (EOC). We evaluated the combined effects of EOC susceptibility SNPs on predicting EOC risk in an independent prospective cohort study. METHODS We genotyped ovarian cancer susceptibility single nucleotide polymorphisms (SNPs) in a nested case-control study (750 cases and 1428 controls) from the UK Collaborative Trial of Ovarian Cancer Screening trial. Polygenic risk scores (PRSs) were constructed and their associations with EOC risk were evaluated using logistic regression. The absolute risk of developing ovarian cancer by PRS percentiles was calculated. RESULTS The association between serous PRS and serous EOC (OR 1.43, 95% CI 1.29 to 1.58, p=1.3×10-11) was stronger than the association between overall PRS and overall EOC risk (OR 1.32, 95% CI 1.21 to 1.45, p=5.4×10-10). Women in the top fifth percentile of the PRS had a 3.4-fold increased EOC risk compared with women in the bottom 5% of the PRS, with the absolute EOC risk by age 80 being 2.9% and 0.9%, respectively, for the two groups of women in the population. CONCLUSION PRSs can be used to predict future risk of developing ovarian cancer for women in the general population. Incorporation of PRSs into risk prediction models for EOC could inform clinical decision-making and health management.
Collapse
Affiliation(s)
- Xin Yang
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Goska Leslie
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Andy Ryan
- Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
| | - Maria Intermaggio
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Lee
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jatinderpal K Kalsi
- Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
| | - Jonathan Tyrer
- Department of Oncology, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Faiza Gaba
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Ranjit Manchanda
- Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, UK
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Paul D P Pharoah
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Department of Oncology, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - Simon A Gayther
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Susan J Ramus
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
- The Kinghorn Cancer Centre, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Ian Jacobs
- Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
- University of New South Wales, Sydney, New South Wales, Australia
- University of Manchester, Manchester, UK
| | - Usha Menon
- Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
| | - Antonis C Antoniou
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| |
Collapse
|
28
|
Perimenopausal management of ovarian endometriosis and associated cancer risk: When is medical or surgical treatment indicated? Best Pract Res Clin Obstet Gynaecol 2018; 51:151-168. [DOI: 10.1016/j.bpobgyn.2018.01.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/23/2018] [Indexed: 12/12/2022]
|
29
|
Manchanda R, Patel S, Gordeev VS, Antoniou AC, Smith S, Lee A, Hopper JL, MacInnis RJ, Turnbull C, Ramus SJ, Gayther SA, Pharoah PDP, Menon U, Jacobs I, Legood R. Cost-effectiveness of Population-Based BRCA1, BRCA2, RAD51C, RAD51D, BRIP1, PALB2 Mutation Testing in Unselected General Population Women. J Natl Cancer Inst 2018; 110:714-725. [PMID: 29361001 DOI: 10.1093/jnci/djx265] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 11/20/2017] [Indexed: 02/11/2024] Open
Abstract
Background The cost-effectiveness of population-based panel testing for high- and moderate-penetrance ovarian cancer (OC)/breast cancer (BC) gene mutations is unknown. We evaluate the cost-effectiveness of population-based BRCA1/BRCA2/RAD51C/RAD51D/BRIP1/PALB2 mutation testing compared with clinical criteria/family history (FH) testing in unselected general population women. Methods A decision-analytic model comparing lifetime costs and effects of criteria/FH-based BRCA1/BRCA2 testing is compared with BRCA1/BRCA2/RAD51C/RAD51D/BRIP1/PALB2 testing in those fulfilling clinical criteria/strong FH of cancer (≥10% BRCA1/BRCA2 probability) and all women age 30 years or older. Analyses are presented for UK and US populations. Identified carriers undergo risk-reducing salpingo-oophorectomy. BRCA1/BRCA2/PALB2 carriers can opt for magnetic resonance imaging/mammography, chemoprevention, or risk-reducing mastectomy. One-way and probabilistic sensitivity analysis (PSA) enabled model uncertainty evaluation. Outcomes include OC, BC, and additional heart disease deaths. Quality-adjusted life-years (QALYs), OC incidence, BC incidence, and incremental cost-effectiveness ratio (ICER) were calculated. The time horizon is lifetime and perspective is payer. Results Compared with clinical criteria/FH-based BRCA1/BRCA2 testing, clinical criteria/FH-based BRCA1/BRCA2/RAD51C/RAD51D/BRIP1/PALB2 testing is cost-effective (ICER = £7629.65/QALY or $49 282.19/QALY; 0.04 days' life-expectancy gained). Population-based testing for BRCA1/BRCA2/RAD51C/RAD51D/BRIP1/PALB2 mutations is the most cost-effective strategy compared with current policy: ICER = £21 599.96/QALY or $54 769.78/QALY (9.34 or 7.57 days' life-expectancy gained). At £30 000/QALY and $100 000/QALY willingness-to-pay thresholds, population-based BRCA1/BRCA2/RAD51C/RAD51D/BRIP1/PALB2 panel testing is the preferred strategy in 83.7% and 92.7% of PSA simulations; criteria/FH-based panel testing is preferred in 16.2% and 5.8% of simulations, respectively. Population-based BRCA1/BRCA2/RAD51C/RAD51D/BRIP1/PALB2 testing can prevent 1.86%/1.91% of BC and 3.2%/4.88% of OC in UK/US women: 657/655 OC cases and 2420/2386 BC cases prevented per million. Conclusions Population-based BRCA1/BRCA2/RAD51C/RAD51D/BRIP1/PALB2 testing is more cost-effective than any clinical criteria/FH-based strategy. Clinical criteria/FH-based BRCA1/BRCA2/RAD51C/RAD51D/BRIP1/PALB2 testing is more cost-effective than BRCA1/BRCA2 testing alone.
Collapse
Affiliation(s)
- Ranjit Manchanda
- Centre for Experimental Cancer Medicine, Queen Mary University of London, London, UK
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London, UK
- Gynaecological Cancer Research Centre, Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
| | - Shreeya Patel
- Centre for Experimental Cancer Medicine, Queen Mary University of London, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Vladimir S Gordeev
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Antonis C Antoniou
- Centre for Cancer Genetic Epidemiology, University of Cambridge, Strangeways Research Laboratory, Worts Causeway, Cambridge, UK
| | - Shantel Smith
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Lee
- Centre for Cancer Genetic Epidemiology, University of Cambridge, Strangeways Research Laboratory, Worts Causeway, Cambridge, UK
| | - John L Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Robert J MacInnis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clare Turnbull
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Susan J Ramus
- Faculty of Medicine, School of Women's and Children's Health, University of New South Wales, Sydney, Australia
- The Kinghorn Cancer Centre, Garvan Institute of Medical Research, Australia
| | | | - Paul D P Pharoah
- Centre for Cancer Genetic Epidemiology, University of Cambridge, Strangeways Research Laboratory, Worts Causeway, Cambridge, UK
| | - Usha Menon
- Gynaecological Cancer Research Centre, Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
| | - Ian Jacobs
- Gynaecological Cancer Research Centre, Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
- University of New South Wales, Sydney, NSW, Australia
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
30
|
Manchanda R, Legood R, Antoniou AC, Pearce L, Menon U. Commentary on changing the risk threshold for surgical prevention of ovarian cancer. BJOG 2018; 125:541-544. [PMID: 28548227 DOI: 10.1111/1471-0528.14763] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2017] [Indexed: 12/12/2022]
Affiliation(s)
- R Manchanda
- Barts Cancer Institute, Queen Mary University of London, London, UK
- Department of Gynaecological Oncology, St Bartholomew's Hospital, London, UK
- Department of Women's Cancer, Gynaecological Cancer Research Centre, Institute for Women's Health, University College London, London, UK
| | - R Legood
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - A C Antoniou
- Strangeways Research Laboratory, Department of Public Health and Primary Care, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, UK
| | - L Pearce
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Department of Preventive Medicine, USC Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - U Menon
- Department of Women's Cancer, Gynaecological Cancer Research Centre, Institute for Women's Health, University College London, London, UK
| |
Collapse
|
31
|
Setting the Threshold for Surgical Prevention in Women at Increased Risk of Ovarian Cancer. Int J Gynecol Cancer 2018; 28:34-42. [DOI: 10.1097/igc.0000000000001147] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AbstractThe number of ovarian cancer cases is predicted to rise by 14% in Europe and 55% worldwide over the next 2 decades. The current absence of a screening program, rising drug/treatment costs, and only marginal improvements in survival seen over the past 30 years suggest the need for maximizing primary surgical prevention to reduce the burden of ovarian cancer. Primary surgical prevention through risk-reducing salpingo-oophorectomy (RRSO) is well established as the most effective method for preventing ovarian cancer. In the UK, it has traditionally been offered to high-risk women (>10% lifetime risk of ovarian cancer) who have completed their family. The cost-effectiveness of RRSO in BRCA1/BRCA2 carriers older than 35 years is well established. Recently, RRSO has been shown to be cost-effective in postmenopausal women at lifetime ovarian cancer risks of 5% or greater and in premenopausal women at lifetime risks greater than 4%. The acceptability, uptake, and satisfaction with RRSO at these intermediate-risk levels remain to be established. Prospective outcome data on risk-reducing salpingectomy and delayed-oophorectomy for preventing ovarian cancer is lacking, and hence, this is best offered for primary prevention within the context and safe environment of a clinical trial. An estimated 63% of ovarian cancers occur in women with greater than 4% lifetime risk and 53% in those with 5% or greater lifetime-risk. Risk-reducing salpingo-oophorectomy can be offered for primary surgical prevention to women at intermediate risk levels (4%–5% to 10%). This includes unaffected women who have completed their family and have RAD51C, RAD51D, or BRIP1 gene mutations; first-degree relatives of women with invasive epithelial ovarian cancer; BRCA mutation–negative women from high-risk breast-and-ovarian cancer or ovarian-cancer-only families. In those with BRCA1, RAD51C/RAD51D/MMR mutations and the occasional families with a history of ovarian cancer in their 40s, surgery needs to be considered at younger than 45. In other moderate-risk gene mutation carriers and those with polygenic risk, RRSO needs be considered at 50. There is need for establishment/expansion of well-defined pathways to increase clinical access to RRSO. It is time to lower the risk threshold for RRSO to enable introduction of a targeted primary prevention approach, which could significantly impact the future burden of ovarian cancer.
Collapse
|
32
|
Hann KEJ, Fraser L, Side L, Gessler S, Waller J, Sanderson SC, Freeman M, Jacobs I, Lanceley A. Health care professionals' attitudes towards population-based genetic testing and risk-stratification for ovarian cancer: a cross-sectional survey. BMC WOMENS HEALTH 2017; 17:132. [PMID: 29246147 PMCID: PMC5732525 DOI: 10.1186/s12905-017-0488-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 11/30/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Ovarian cancer is usually diagnosed at a late stage when outcomes are poor. Personalised ovarian cancer risk prediction, based on genetic and epidemiological information and risk stratified management in adult women could improve outcomes. Examining health care professionals' (HCP) attitudes to ovarian cancer risk stratified management, willingness to support women, self-efficacy (belief in one's own ability to successfully complete a task), and knowledge about ovarian cancer will help identify training needs in anticipation of personalised ovarian cancer risk prediction being introduced. METHODS An anonymous survey was distributed online to HCPs via relevant professional organisations in the UK. Kruskal-Wallis tests and pairwise comparisons were used to compare knowledge and self-efficacy scores between different types of HCPs, and attitudes toward population-based genetic testing and risk stratified management were described. Content analysis was undertaken of free text responses concerning HCPs willingness to discuss risk management options with women. RESULTS One hundred forty-six eligible HCPs completed the survey: oncologists (31%); genetics clinicians (30%); general practitioners (22%); gynaecologists (10%); nurses (4%); and 'others'. Scores for knowledge of ovarian cancer and genetics, and self-efficacy in conducting a cancer risk consultation were generally high but significantly lower for general practitioners compared to genetics clinicians, oncologists, and gynaecologists. Support for population-based genetic testing was not high (<50%). Attitudes towards ovarian cancer risk stratification were mixed, although the majority of participants indicated a willingness to discuss management options with patients. CONCLUSIONS Larger samples are required to investigate attitudes to population-based genetic testing for ovarian cancer risk and to establish why some HCPs are hesitant to offer testing to all adult female patients. If ovarian cancer risk assessment using genetic testing and non-genetic information including epidemiological information is rolled out on a population basis, training will be needed for HCPs in primary care to enable them to provide appropriate support to women at each stage of the process.
Collapse
Affiliation(s)
- Katie E J Hann
- Department of Women's Cancer, EGA UCL Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK
| | - Lindsay Fraser
- Department of Women's Cancer, EGA UCL Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK
| | - Lucy Side
- Department of Women's Cancer, EGA UCL Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sue Gessler
- Department of Women's Cancer, EGA UCL Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK
| | - Jo Waller
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Saskia C Sanderson
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK.,Great Ormond Street Hospital, London, UK
| | - Madeleine Freeman
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Ian Jacobs
- Department of Women's Cancer, EGA UCL Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.,The University of New South Wales, Sydney, NSW, Australia
| | - Anne Lanceley
- Department of Women's Cancer, EGA UCL Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.
| | | |
Collapse
|
33
|
Abstract
Women carrying germline mutations in BRCA1 or BRCA2 have significantly increased lifetime risks of breast and tubo-ovarian cancer. To manage the breast cancer risk women may elect to have breast screening by MRI/mammogram from age 30, to take risk-reducing medication, or to have a prophylactic bilateral mastectomy. To manage the tubo-ovarian cancer risk, the only effective strategy is to have a bilateral salpingo-oophorectomy, recommended by age 40 (BRCA1) or 'around' age 40 (BRCA2). Early studies suggested that uptake of these cancer risk-reducing strategies was low. More recent studies have revealed higher rates of uptake, however it is unclear whether uptake is genuinely improving or whether the higher uptake rates reflect changes in the populations studied. In this study we surveyed 193 BRCA1/2 mutation carriers in the state of Tasmania to determine the uptake of cancer risk-reducing strategies and what factors might influence women's decisions in relation to both gynaecological and breast surgery. We observed that uptake of risk management strategies varied depending on the strength of the recommendation in the national guidelines. Uptake rates were > 90% for strategies which are strongly recommended, such as breast screening by MRI/mammogram and bilateral salpingo-oophorectomy, and were unaffected by demographic factors such as socio-economic disadvantage and educational achievement. Uptake rates were much lower for strategies which are presented in the guidelines as options for consideration and where patient choice and shared decision making are encouraged, such as prophylactic mastectomy (29%) and chemoprevention (1%) and in the case of prophylactic mastectomy, were influenced by both socio-economic advantage and educational achievement.
Collapse
|
34
|
Abstract
Ovarian cancer remains to be the most lethal of all gynecologic malignancies. There is no effective screening test proven to reduce the mortality associated with this disease. Costs of treating ovarian cancer are substantial and among the highest of all cancer types. Therefore, it is essential to pursue strategies to prevent ovarian cancer that are cost-effective in the context of our health care system. There are 2 subgroups of women for whom ovarian cancer prevention strategies have been evaluated for effectiveness and costs: (1) general population at risk, and (2) BRCA mutation carriers with a high lifetime risk.
Collapse
|
35
|
Manchanda R, Legood R, Antoniou AC, Gordeev VS, Menon U. Specifying the ovarian cancer risk threshold of 'premenopausal risk-reducing salpingo-oophorectomy' for ovarian cancer prevention: a cost-effectiveness analysis. J Med Genet 2016; 53:591-9. [PMID: 27354448 DOI: 10.1136/jmedgenet-2016-103800] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 04/01/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Risk-reducing salpingo-oophorectomy (RRSO) is the most effective intervention to prevent ovarian cancer (OC). It is only available to high-risk women with >10% lifetime OC risk. This threshold has not been formally tested for cost-effectiveness. OBJECTIVE To specify the OC risk thresholds for RRSO being cost-effective for preventing OC in premenopausal women. METHODS The costs as well as effects of surgical prevention ('RRSO') were compared over a lifetime with 'no RRSO' using a decision analysis model. RRSO was undertaken in premenopausal women >40 years. The model was evaluated at lifetime OC risk levels: 2%, 4%, 5%, 6%, 8% and 10%. Costs and outcomes are discounted at 3.5%. Uncertainty in the model was assessed using both deterministic sensitivity analysis and probabilistic sensitivity analysis (PSA). Outcomes included in the analyses were OC, breast cancer (BC) and additional deaths from coronary heart disease. Total costs and effects were estimated in terms of quality-adjusted life-years (QALYs); incidence of OC and BC; as well as incremental cost-effectiveness ratio (ICER). DATA SOURCES Published literature, Nurses Health Study, British National Formulary, Cancer Research UK, National Institute for Health and Care Excellence guidelines and National Health Service reference costs. The time horizon is lifetime and perspective: payer. RESULTS Premenopausal RRSO is cost-effective at 4% OC risk (life expectancy gained=42.7 days, ICER=£19 536/QALY) with benefits largely driven by reduction in BC risk. RRSO remains cost-effective at >8.2% OC risk without hormone replacement therapy (ICER=£29 071/QALY, life expectancy gained=21.8 days) or 6%if BC risk reduction=0 (ICER=£27 212/QALY, life expectancy gained=35.3 days). Sensitivity analysis indicated results are not impacted much by costs of surgical prevention or treatment of OC/ BC or cardiovascular disease. However, results were sensitive to RRSO utility scores. Additionally, 37%, 61%, 74%, 84%, 96% and 99.5% simulations on PSA are cost-effective for RRSO at the 2%, 4%, 5%, 6%, 8% and 10% levels of OC risk, respectively. CONCLUSIONS Premenopausal RRSO appears to be extremely cost-effective at ≥4% lifetime OC risk, with ≥42.7 days gain in life expectancy if compliance with hormone replacement therapy is high. Current guidelines should be re-evaluated to reduce the RRSO OC risk threshold to benefit a number of at-risk women who presently cannot access risk-reducing surgery.
Collapse
Affiliation(s)
- Ranjit Manchanda
- Barts Cancer Institute, Queen Mary University of London, London, UK Department of Women's Cancer, Gynaecological Cancer Research Centre, Institute for Women's Health, University College London, London, UK Department of Gynaecological Oncology, St Bartholomew's Hospital, London, UK
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Antonis C Antoniou
- Centre for Cancer Genetic Epidemiology, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Vladimir S Gordeev
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Usha Menon
- Department of Women's Cancer, Gynaecological Cancer Research Centre, Institute for Women's Health, University College London, London, UK
| |
Collapse
|