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Bommer C, Lupatsch J, Bürki N, Schwenkglenks M. Cost-utility analysis of risk-reducing strategies to prevent breast and ovarian cancer in BRCA-mutation carriers in Switzerland. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:807-821. [PMID: 34767113 PMCID: PMC9170622 DOI: 10.1007/s10198-021-01396-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 10/21/2021] [Indexed: 05/02/2023]
Abstract
OBJECTIVE We aimed to identify the most cost-effective of all prophylactic measures available in Switzerland for women not yet affected by breast and ovarian cancer who tested positive for a BRCA1/2 mutation. METHODS Prophylactic bilateral mastectomy (PBM), salpingo-oophorectomy (PBSO), combined PBM&PBSO and chemoprevention (CP) initiated at age 40 years were compared with intensified surveillance (IS). A Markov model with a life-long time horizon was developed from the perspective of the Swiss healthcare system using mainly literature-derived data to evaluate costs, quality-adjusted life years (QALYs) and survival. Costs and QALYs were discounted by 3% per year. Robustness of the results was tested with deterministic and probabilistic sensitivity analyses. RESULTS All prophylactic measures were found to be cost-saving with an increase in QALYs and life years (LYs) compared to IS. PBM&PBSO were found to be most cost-effective and dominated all other strategies in women with a BRCA1 or BRCA2 mutation. Lifetime costs averaged to 141,293 EUR and 14.5 QALYs per woman with a BRCA1 mutation under IS, versus 76,639 EUR and 19.2 QALYs for PBM&PBSO. Corresponding results for IS per woman with a BRCA2 mutation were 102,245 EUR and 15.5 QALYs, versus 60,770 EUR and 19.9 QALYs for PBM&PBSO. The results were found to be robust in sensitivity analysis; no change in the dominant strategy for either BRCA-mutation was observed. CONCLUSION All more invasive strategies were found to increase life expectancy and quality of life of women with a BRCA1 or BRCA2 mutation and were cost-saving for the Swiss healthcare system compared to IS.
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Affiliation(s)
- Claudine Bommer
- University of Zurich, Zürich, Switzerland.
- Department of Gynaecological Oncology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Judith Lupatsch
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
| | - Nicole Bürki
- Gynaecological Tumor Center, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Matthias Schwenkglenks
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
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Sun L, Cui B, Wei X, Sadique Z, Yang L, Manchanda R, Legood R. Cost-Effectiveness of Genetic Testing for All Women Diagnosed with Breast Cancer in China. Cancers (Basel) 2022; 14:cancers14071839. [PMID: 35406611 PMCID: PMC8997428 DOI: 10.3390/cancers14071839] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Unselected multigene testing at breast cancer (BC) diagnosis has been reported to be cost-effective compared with family history (FH)/clinical-criteria-based testing in high-income countries such as the US and UK. Chinese patients are younger than Caucasian women at diagnosis, tending to have a higher gene mutation prevalence, and the family size and number of female relatives are smaller due to the one-child policy (which has been changed) in China. Therefore, offering genetic testing for BC patients could potentially prevent more cancer cases and deaths in China. However, the health economic evidence for multigene testing at BC diagnosis in China is lacking. The aim of the current study was to evaluate the cost-effectiveness of three genetic testing strategies among BC patients using a microsimulation model at the individual level in China. We found that offering unselected multigene testing to all BC patients in China is highly cost-effective compared with FH/clinical-criteria-based testing or no testing from both the societal and payer perspectives. Abstract Unselected multigene testing for all women with breast cancer (BC) identifies more cancer susceptibility gene (CSG) carriers who can benefit from precision prevention compared with family history (FH)/clinical-criteria-based guidelines. Very little CSG testing is undertaken in middle-income countries such as China, and its cost-effectiveness remains unaddressed. We aimed to estimate cost-effectiveness and population impact of multigene testing for all Chinese BC patients. Data from 8085 unselected BC patients recruited to a Peking University Cancer Hospital study were used for microsimulation modeling, comparing three strategies in the Chinese setting: all BC women undergo BRCA1/BRCA2/PALB2 genetic testing, only BC women fulfilling FH/clinical criteria undergo BRCA testing, and no genetic testing. Prophylactic mastectomy and salpingo-oophorectomy would be adopted where appropriate. Societal and payer perspectives with a lifetime horizon along with sensitivity analyses were presented. Incremental cost-effectiveness ratio (ICER): incremental cost per quality-adjusted life-year (QALY) gained is compared to the USD 10,260/QALY (one-times GDP per capita) willingness-to-pay threshold. BC incidence, ovarian cancer (OC) incidence, and related deaths were also estimated. FH/clinical-criteria-based BRCA testing was ruled out on the principle of extensive dominance. Compared with no genetic testing, multigene testing for all BC patients had an ICER = USD 4506/QALY (societal perspective) and USD 7266/QALY (payer perspective), well below our threshold. Probabilistic sensitivity analysis showed unselected multigene testing remained cost-effective for 94.2%/86.6% of simulations from the societal and payer perspectives. One year’s unselected multigene testing could prevent 7868 BC/OC cases and 5164 BC/OC deaths in China. Therefore, unselected multigene testing is extremely cost-effective and should be offered to all Chinese women with BC.
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Affiliation(s)
- Li Sun
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
- Wolfson Institute for Population Health, CRUK Barts Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK
| | - Bin Cui
- School of Public Health, Peking University, Beijing 100191, China
| | - Xia Wei
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
- Wolfson Institute for Population Health, CRUK Barts Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK
- School of Public Health, Peking University, Beijing 100191, China
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
| | - Li Yang
- School of Public Health, Peking University, Beijing 100191, China
| | - Ranjit Manchanda
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
- Wolfson Institute for Population Health, CRUK Barts Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, UK
- Department of Gynaecology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
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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.
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Conduit C, Milne RL, Friedlander ML, Phillips KA. Bilateral Salpingo-oophorectomy and Breast Cancer Risk for BRCA1 and BRCA2 Mutation Carriers: Assessing the Evidence. Cancer Prev Res (Phila) 2021; 14:983-994. [PMID: 34348913 PMCID: PMC9662899 DOI: 10.1158/1940-6207.capr-21-0141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/24/2021] [Accepted: 07/20/2021] [Indexed: 01/07/2023]
Abstract
Without preventive interventions, women with germline pathogenic variants in BRCA1 or BRCA2 have high lifetime risks for breast cancer and tubo-ovarian cancer. The increased risk for breast cancer starts at a considerably younger age than that for tubo-ovarian cancer. Risk-reducing bilateral salpingo-oophorectomy (rrBSO) is effective in reducing tubo-ovarian cancer risk for BRCA1 and BRCA2 mutation carriers, but whether it reduces breast cancer risk is less clear. All studies of rrBSO and breast cancer risk are observational in nature and subject to various forms of bias and confounding, thus limiting conclusions that can be drawn about causation. Early studies supported a statistically significant protective association for rrBSO on breast cancer risk, which is reflected by several international guidelines that recommend consideration of premenopausal rrBSO for breast cancer risk reduction. However, these historical studies were hampered by the presence of several important biases, including immortal person-time bias, confounding by indication, informative censoring, and confounding by other risk factors, which may have led to overestimation of any protective benefit. Contemporary studies, specifically designed to reduce some of these biases, have yielded contradictory results. Taken together, there is no clear and consistent evidence for a role of premenopausal rrBSO in reducing breast cancer risk in BRCA1 or BRCA2 mutation carriers.
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Affiliation(s)
- Ciara Conduit
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Roger L. Milne
- Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.,Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Michael L. Friedlander
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Department of Medical Oncology, Prince of Wales Hospital, Barker St. Randwick, New South Wales, Australia
| | - Kelly-Anne Phillips
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia.,Corresponding Author: Kelly-Anne Phillips, Department of Medical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St., Melbourne, Victoria, 3000, Australia. Phone: 613-8559-7902; Fax: 613-8559-7739; E-mail:
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5
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Association of premenopausal risk-reducing salpingo-oophorectomy with breast cancer risk in BRCA1/2 mutation carriers: Maximising bias-reduction. Eur J Cancer 2020; 132:53-60. [PMID: 32325420 DOI: 10.1016/j.ejca.2020.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 02/28/2020] [Accepted: 03/09/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Whether risk-reducing salpingo-oophorectomy (RRSO) in BRCA1/2 carriers reduces the breast cancer (BC) risk is conflicting, potentially due to methodological issues of prior analysis. We analysed the association between premenopausal RRSO and BC risk in BRCA1/2 carriers after adjusting for potential biases. METHODS We analysed data from 444 BRCA1 and 409 BRCA2 carriers under age 51 with no cancer prior to genetic testing or during first 6 months of surveillance (to avoid cancer-induced testing bias and prevalent-cancer bias). Observation started 6 months after genetic testing (to avoid event-free time bias), until BC diagnosis, risk-reducing mastectomy (RRM) or death. A multistate model with four states (non-RRSO, RRSO, RRM and BC) and five transitions was fitted to characterise outcomes and to calculate the BC risk reduction after premenopausal RRSO (before age 51). A systematic review was performed to assess the association between premenopausal RRSO and BC. RESULTS During a mean follow-up of 4.3 years, 96 women (11.3%) developed BC (54 BRCA1, 42 BRCA2). The risk of BC after premenopausal RRSO decreased significantly in BRCA1 carriers (hazard ratio (HR) = 0.45 [95% confidence interval (CI):0.22-0.92]), but was not conclusive in BRCA2 carriers (HR = 0.77 [95%CI:0.35-1.67]). The systematic review suggested that premenopausal RRSO is associated with a decrease of BC risk in both BRCA1 and BRCA2 carriers. CONCLUSIONS Premenopausal RRSO was associated with BC risk reduction in BRCA1 carriers, which can help guide cancer risk-reducing strategies in this population. Longer follow-up and larger sample size may be needed to estimate the potential benefit in BRCA2 carriers.
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Sun L, Brentnall A, Patel S, Buist DSM, Bowles EJA, Evans DGR, Eccles D, Hopper J, Li S, Southey M, Duffy S, Cuzick J, dos Santos Silva I, Miners A, Sadique Z, Yang L, Legood R, Manchanda R. A Cost-effectiveness Analysis of Multigene Testing for All Patients With Breast Cancer. JAMA Oncol 2019; 5:1718-1730. [PMID: 31580391 PMCID: PMC6777250 DOI: 10.1001/jamaoncol.2019.3323] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 06/19/2019] [Indexed: 02/06/2023]
Abstract
Importance Moving to multigene testing for all women with breast cancer (BC) could identify many more mutation carriers who can benefit from precision prevention. However, the cost-effectiveness of this approach remains unaddressed. Objective To estimate incremental lifetime effects, costs, and cost-effectiveness of multigene testing of all patients with BC compared with the current practice of genetic testing (BRCA) based on family history (FH) or clinical criteria. Design, Setting, and Participants This cost-effectiveness microsimulation modeling study compared lifetime costs and effects of high-risk BRCA1/BRCA2/PALB2 (multigene) testing of all unselected patients with BC (strategy A) with BRCA1/BRCA2 testing based on FH or clinical criteria (strategy B) in United Kingdom (UK) and US populations. Data were obtained from 11 836 patients in population-based BC cohorts (regardless of FH) recruited to 4 large research studies. Data were collected and analyzed from January 1, 2018, through June 8, 2019. The time horizon is lifetime. Payer and societal perspectives are presented. Probabilistic and 1-way sensitivity analyses evaluate model uncertainty. Interventions In strategy A, all women with BC underwent BRCA1/BRCA2/PALB2 testing. In strategy B, only women with BC fulfilling FH or clinical criteria underwent BRCA testing. Affected BRCA/PALB2 carriers could undertake contralateral preventive mastectomy; BRCA carriers could choose risk-reducing salpingo-oophorectomy (RRSO). Relatives of mutation carriers underwent cascade testing. Unaffected relative carriers could undergo magnetic resonance imaging or mammography screening, chemoprevention, or risk-reducing mastectomy for BC risk and RRSO for ovarian cancer (OC) risk. Main Outcomes and Measures Incremental cost-effectiveness ratio (ICER) was calculated as incremental cost per quality-adjusted life-year (QALY) gained and compared with standard £30 000/QALY and $100 000/QALY UK and US thresholds, respectively. Incidence of OC, BC, excess deaths due to heart disease, and the overall population effects were estimated. Results BRCA1/BRCA2/PALB2 multigene testing for all patients detected with BC annually would cost £10 464/QALY (payer perspective) or £7216/QALY (societal perspective) in the United Kingdom or $65 661/QALY (payer perspective) or $61 618/QALY (societal perspective) in the United States compared with current BRCA testing based on clinical criteria or FH. This is well below UK and US cost-effectiveness thresholds. In probabilistic sensitivity analysis, unselected multigene testing remained cost-effective for 98% to 99% of UK and 64% to 68% of US health system simulations. One year's unselected multigene testing could prevent 2101 cases of BC and OC and 633 deaths in the United Kingdom and 9733 cases of BC and OC and 2406 deaths in the United States. Correspondingly, 8 excess deaths due to heart disease occurred in the United Kingdom and 35 in the United States annually. Conclusions and Relevance This study found unselected, high-risk multigene testing for all patients with BC to be extremely cost-effective compared with testing based on FH or clinical criteria for UK and US health systems. These findings support changing current policy to expand genetic testing to all women with BC.
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Affiliation(s)
- Li Sun
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Adam Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Shreeya Patel
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Diana S. M. Buist
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Erin J. A. Bowles
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - D. Gareth R. Evans
- Genomic Medicine, Manchester Academic Health Science Centre, Manchester Universities Foundation Trust, St Mary’s Hospital, The University of Manchester, Manchester, United Kingdom
| | - Diana Eccles
- Cancer Sciences Academic Unit, Faculty of Medicine and Cancer Sciences, University of Southampton, Southampton, United Kingdom
| | - John Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Shuai Li
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Melissa Southey
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
- Department of Clinical Pathology, Melbourne Medical School, Melbourne University, Melbourne, Australia
- Cancer Epidemiology Division, Cancer Council Victoria, Victoria, Australia
| | - Stephen Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Isabel dos Santos Silva
- Department of Noncommunicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 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
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
- Department of Gynaecological Oncology, Barts Health National Health System Trust, Royal London Hospital, London, United Kingdom
- MRC (Medical Research Counsel) Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, Faculty of Population Health Sciences, University College London, London, United Kingdom
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Mai PL, Miller A, Gail MH, Skates S, Lu K, Sherman ME, Ioffe OB, Rodriguez G, Cohn DE, Boggess J, Rutherford T, Kauff ND, Rader JS, Phillips KA, DiSilvestro PA, Olawaiye AB, Ridgway MR, Greene MH, Piedmonte M, Walker JL. Risk-Reducing Salpingo-Oophorectomy and Breast Cancer Risk Reduction in the Gynecologic Oncology Group Protocol-0199 (GOG-0199). JNCI Cancer Spectr 2019; 4:pkz075. [PMID: 32337492 DOI: 10.1093/jncics/pkz075] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/18/2019] [Accepted: 10/02/2019] [Indexed: 12/14/2022] Open
Abstract
Background Risk-reducing salpingo-oophorectomy (RRSO) has been associated with approximately 50% breast cancer risk reduction among women with a pathogenic variant in BRCA1 or BRCA2 (BRCA1/2), a finding that has recently been questioned. Methods We estimated incidence rates of breast cancer and all cancers combined during 5 years of follow-up among participants selecting RRSO or ovarian cancer screening (OCS) among women with a BRCA1/2 pathogenic variant or strong breast and/or ovarian cancer family history. Ovarian or fallopian tube or peritoneal cancer incidence rates were estimated for the OCS group. Breast cancer hazard ratios (HRs) for time-dependent RRSO were estimated using Cox regression with age time-scale (4943 and 4990 women-years in RRSO and OCS cohorts, respectively). All statistical tests were two-sided. Results The RRSO cohort included 925 participants, and 1453 participants were in the OCS cohort (381 underwent RRSO during follow-up), with 88 incident breast cancers diagnosed. Among BRCA1/2 pathogenic variant carriers, a non-statistically significant lower breast cancer incidence was observed in the RRSO compared with the OCS cohort (HR = 0.86, 95% confidence interval = 0.45 to 1.67; P = .67). No difference was observed in the overall population or among subgroups stratified by prior breast cancer history or menopausal status. Seven fallopian tube and four ovarian cancers were prospectively diagnosed in the OCS cohort, and one primary peritoneal carcinoma occurred in the RRSO cohort. Conclusions These data suggest that RRSO might be associated with reduced breast cancer incidence among women with a BRCA1/2 pathogenic variant, although the effect, if present, is small. This evolving evidence warrants a thorough discussion regarding the impact of RRSO on breast cancer risk with women considering this intervention.
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Affiliation(s)
- Phuong L Mai
- Clinical Genetics Branch, National Cancer Institute, Rockville, MD
| | - Austin Miller
- NRG Oncology, Statistical and Data Center, Roswell Park Cancer Institute, Buffalo, NY
| | - Mitchell H Gail
- Biostatistics Branch, National Cancer Institute, Rockville, MD
| | - Steven Skates
- Department of Biostatistics Unit, Massachusetts General Hospital, Boston, MA
| | - Karen Lu
- Department of GYN Oncology, MD Anderson Cancer Center, Houston, TX
| | - Mark E Sherman
- Division of Cancer Epidemiology and Genetics, and Environmental Epidemiology Branch, National Cancer Institute, Rockville, MD
| | - Olga B Ioffe
- Department of Pathology, University of Maryland Medical Center, Baltimore, MD
| | - Gustavo Rodriguez
- Division of Gynecologic Oncology, NorthShore University Health System, Evanston, IL.,Department of Obstetrics and Gynecology, University of Chicago, Evanston, IL
| | - David E Cohn
- Division of Gynecologic Oncology, Ohio State University, Columbus, OH
| | - John Boggess
- Division of Gynecologic Oncology, University of North Carolina at Chapel Hill, Raleigh, NC
| | | | - Noah D Kauff
- Gynecology and Clinical Genetics Services, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Janet S Rader
- Division of Gynecologic Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Kelly-Anne Phillips
- Division of Cancer Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, Australia
| | - Paul A DiSilvestro
- Department of Obstetrics & Gynecology, Women & Infants Hospital, Providence, RI
| | - Alexander B Olawaiye
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Magee-Womens Hospital of UPMC, Pittsburgh, PA
| | | | - Mark H Greene
- Clinical Genetics Branch, National Cancer Institute, Rockville, MD
| | - Marion Piedmonte
- NRG Oncology, Statistical and Data Center, Roswell Park Cancer Institute, Buffalo, NY
| | - Joan L Walker
- Department of OB/GYN, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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8
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Kotsopoulos J, Lubinski J, Lynch HT, Tung N, Armel S, Senter L, Singer CF, Fruscio R, Couch F, Weitzel JN, Karlan B, Foulkes WD, Moller P, Eisen A, Ainsworth P, Neuhausen SL, Olopade O, Sun P, Gronwald J, Narod SA. Oophorectomy and risk of contralateral breast cancer among BRCA1 and BRCA2 mutation carriers. Breast Cancer Res Treat 2019; 175:443-449. [PMID: 30756284 DOI: 10.1007/s10549-019-05162-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/05/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Following a diagnosis of breast cancer, BRCA mutation carriers face an increased risk of developing a second (contralateral) cancer in the unaffected breast. It is important to identify predictors of contralateral cancer in order to make informed decisions about bilateral mastectomy. The impact of bilateral salpingo-oophorectomy (i.e., oophorectomy) on the risk of developing contralateral breast cancer is unclear. Thus, we conducted a prospective study of the relationship between oophorectomy and the risk of contralateral breast cancer in 1781 BRCA1 and 503 BRCA2 mutation carriers with breast cancer. METHODS Women were followed from the date of diagnosis of their first breast cancer until the date of diagnosis of a contralateral breast cancer, bilateral mastectomy, date of death, or date of last follow-up. Cox proportional hazards regression was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) of contralateral breast cancer associated with oophorectomy. Oophorectomy was included as a time-dependent covariate. We performed a left-censored analysis for those women who reported a primary breast cancer prior to study entry (i.e., from completion of baseline questionnaire). RESULTS After an average of 9.8 years of follow-up, there were 179 (7.8%) contralateral breast cancers diagnosed. Oophorectomy was not associated with the risk of developing a second breast cancer (HR 0.92; 95% CI 0.68-1.25). The relationship did not vary by BRCA mutation type or by age at diagnosis of the first breast cancer. There was some evidence for a decreased risk of contralateral breast cancer among women with an ER-positive primary breast cancer, but this was based on a small number of events (n = 240). CONCLUSION Overall, our findings suggest that oophorectomy has little impact on the risk of contralateral breast cancer.
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Affiliation(s)
- Joanne Kotsopoulos
- Women's College Research Institute, Women's College Hospital, 76 Grenville St., 6th Floor, Toronto, ON, M5S 1B2, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jan Lubinski
- International Hereditary Cancer Center, Department of Genetics and Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Henry T Lynch
- Department of Preventive Medicine and Public Health, Creighton University School of Medicine, Omaha, NE, USA
| | - Nadine Tung
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Susan Armel
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Leigha Senter
- Division of Human Genetics, Comprehensive Cancer Center, The Ohio State University Medical Center, Columbus, OH, USA
| | - Christian F Singer
- Department of Obstetrics and Gynecology and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Robert Fruscio
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Fergus Couch
- Division of Experimental Pathology and Laboratory Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey N Weitzel
- Division of Clinical Cancer Genomics, Department of Population Sciences, City of Hope, Duarte, CA, USA
| | - Beth Karlan
- Gynecology Oncology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - William D Foulkes
- Program in Cancer Genetics, Department of Oncology and Human Genetics, McGill University, Montreal, QC, Canada
| | - Pal Moller
- Inherited Cancer Research Group, Department for Medical Genetics, Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Andrea Eisen
- Toronto-Sunnybrook Regional Cancer Center, Toronto, ON, Canada
| | - Peter Ainsworth
- Department of Pathology and Laboratory Medicine, Western University, London, ON, Canada
| | - Susan L Neuhausen
- Division of Biomarkers of Early Detection and Prevention, Department of Population Science, City of Hope, Duarte, CA, USA
| | - Olufunmilayo Olopade
- Department of Medicine and Human Genetics, University of Chicago, Chicago, IL, USA
| | - Ping Sun
- Women's College Research Institute, Women's College Hospital, 76 Grenville St., 6th Floor, Toronto, ON, M5S 1B2, Canada
| | - Jacek Gronwald
- International Hereditary Cancer Center, Department of Genetics and Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Steven A Narod
- Women's College Research Institute, Women's College Hospital, 76 Grenville St., 6th Floor, Toronto, ON, M5S 1B2, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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Abstract
The goal of the 2017 North American Menopause Society Hormone Therapy (HT) Position Statement is to remove fear about HT and encourage individualized shared decision making, using best available evidence. Systemic HT is safe and effective for symptomatic menopausal women aged younger than 60 years and within 10 years of menopause. Special populations of early menopause, high risk for fracture, risk of breast or uterine cancer, and extended duration are discussed. With longer duration of use, periodic evaluation and reassessment of health risks are needed. Lowered doses, transdermal therapies or newer options may enhance the benefit:risk ratio for HT.
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Chitalia A, Khoury K, Isaacs C. Risk and Prevention for Highly Penetrant Genes. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0282-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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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.
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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
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NAMS 3rd Utian Translational Science Symposium, October 2016, Orlando, Florida A conversation about hormone therapy: is there an appropriate dose, route, and duration of use? Menopause 2018; 24:1221-1235. [PMID: 28968302 DOI: 10.1097/gme.0000000000000986] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The North American Menopause Society (NAMS) held the 3rd Utian Translational Symposium on October 4, 2016, in Orlando, Florida, to answer questions about the benefits and risks of hormone therapy (HT) for postmenopausal women. This report is a record of the proceedings of that symposium.The maxim about HT for the past 15 years since the publication of the initial results of the Women's Health Initiative (WHI) has been to prescribe the "lowest dose for the shortest period of time." With new clinical trials, observational data, and further analysis of the WHI and the cumulative 13 years' follow-up, it was time to hold a conversation about the state of the evidence and recommendations for HT dose, route, and duration of use.The symposium brought together experts in the field of HT to speak on these topics, organized by session, after which working groups gathered to synthesize the presentations into areas of what still needs to be known and how to proceed with areas of needed research. After the presentations, there was consensus that postmenopausal women aged younger than 60 years or within 10 years of menopause onset without contraindications and who desire to take HT for relief of vasomotor symptoms or prevention of bone loss if at elevated risk can safely do so.The working groups raised the possibility that the use of "Big Data" (pharmacy and cancer databases) would allow answers that cannot be found in clinical trials. This could lead to more appropriate FDA labeling and patient package inserts reflecting the true risks associated with various types and formulations of HT, with differences among estrogen alone, estrogen with a progestogen, and estrogen plus a selective estrogen-receptor modulator for the younger women most likely to initiate these therapies for symptom relief. Differences were found for potential risk among estrogen alone, estrogen with synthetic progestins contrasted to progesterone, lower doses, nonoral doses, and low-dose vaginal estrogen.With all of the available routes and dosages, including vaginal estrogen alone for genitourinary symptoms, there are many options when considering the most appropriate type, dose, formulation, route of administration, and duration of use, taking into account the age of the woman at initiation of HT and the time from menopause.
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Abstract
The 2017 Hormone Therapy Position Statement of The North American Menopause Society (NAMS) updates the 2012 Hormone Therapy Position Statement of The North American Menopause Society and identifies future research needs. An Advisory Panel of clinicians and researchers expert in the field of women's health and menopause was recruited by NAMS to review the 2012 Position Statement, evaluate new literature, assess the evidence, and reach consensus on recommendations, using the level of evidence to identify the strength of recommendations and the quality of the evidence. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees.Hormone therapy (HT) remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture. The risks of HT differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing or discontinuing HT.For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is most favorable for treatment of bothersome VMS and for those at elevated risk for bone loss or fracture. For women who initiate HT more than 10 or 20 years from menopause onset or are aged 60 years or older, the benefit-risk ratio appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia. Longer durations of therapy should be for documented indications such as persistent VMS or bone loss, with shared decision making and periodic reevaluation. For bothersome GSM symptoms not relieved with over-the-counter therapies and without indications for use of systemic HT, low-dose vaginal estrogen therapy or other therapies are recommended.This NAMS position statement has been endorsed by Academy of Women's Health, American Association of Clinical Endocrinologists, American Association of Nurse Practitioners, American Medical Women's Association, American Society for Reproductive Medicine, Asociación Mexicana para el Estudio del Climaterio, Association of Reproductive Health Professionals, Australasian Menopause Society, Chinese Menopause Society, Colegio Mexicano de Especialistas en Ginecologia y Obstetricia, Czech Menopause and Andropause Society, Dominican Menopause Society, European Menopause and Andropause Society, German Menopause Society, Groupe d'études de la ménopause et du vieillissement Hormonal, HealthyWomen, Indian Menopause Society, International Menopause Society, International Osteoporosis Foundation, International Society for the Study of Women's Sexual Health, Israeli Menopause Society, Japan Society of Menopause and Women's Health, Korean Society of Menopause, Menopause Research Society of Singapore, National Association of Nurse Practitioners in Women's Health, SOBRAC and FEBRASGO, SIGMA Canadian Menopause Society, Società Italiana della Menopausa, Society of Obstetricians and Gynaecologists of Canada, South African Menopause Society, Taiwanese Menopause Society, and the Thai Menopause Society. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, June 2017. The British Menopause Society supports this Position Statement.
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Patel S, Legood R, Evans DG, Turnbull C, Antoniou AC, Menon U, Jacobs I, Manchanda R. Cost effectiveness of population based BRCA1 founder mutation testing in Sephardi Jewish women. Am J Obstet Gynecol 2018; 218:431.e1-431.e12. [PMID: 29288066 DOI: 10.1016/j.ajog.2017.12.221] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/08/2017] [Accepted: 12/19/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Population-based BRCA1/BRCA2 founder-mutation testing has been demonstrated as cost effective compared with family history based testing in Ashkenazi Jewish women. However, only 1 of the 3 Ashkenazi Jewish BRCA1/BRCA2 founder mutations (185delAG[c.68_69delAG]), 5382insC[c.5266dupC]), and 6174delT[c.5946delT]) is found in the Sephardi Jewish population (185delAG[c.68_69delAG]), and the overall prevalence of BRCA mutations in the Sephardi Jewish population is accordingly lower (0.7% compared with 2.5% in the Ashkenazi Jewish population). Cost-effectiveness analyses of BRCA testing have not previously been performed at these lower BRCA prevalence levels seen in the Sephardi Jewish population. Here we present a cost-effectiveness analysis for UK and US populations comparing population testing with clinical criteria/family history-based testing in Sephardi Jewish women. STUDY DESIGN A Markov model was built comparing the lifetime costs and effects of population-based BRCA1 testing, with testing using family history-based clinical criteria in Sephardi Jewish women aged ≥30 years. BRCA1 carriers identified were offered magnetic resonance imaging/mammograms and risk-reducing surgery. Costs are reported at 2015 prices. Outcomes include breast cancer, ovarian cancer, and excess deaths from heart disease. All costs and outcomes are discounted at 3.5%. The time horizon is lifetime, and perspective is payer. The incremental cost-effectiveness ratio per quality-adjusted life-year was calculated. Parameter uncertainty was evaluated through 1-way and probabilistic sensitivity analysis. RESULTS Population testing resulted in gain in life expectancy of 12 months (quality-adjusted life-year = 1.00). The baseline discounted incremental cost-effectiveness ratio for UK population-based testing was £67.04/quality-adjusted life-year and for US population was $308.42/quality-adjusted life-year. Results were robust in the 1-way sensitivity analysis. The probabilistic sensitivity analysis showed 100% of simulations were cost effective at £20,000/quality-adjusted life-year UK and the $100,000/quality-adjusted life-year US willingness-to-pay thresholds. Scenario analysis showed that population testing remains cost effective in UK and US populations, even if premenopausal oophorectomy does not reduce breast cancer risk or if hormone replacement therapy compliance is nil. CONCLUSION Population-based BRCA1 testing is highly cost effective compared with clinical criteria-driven approach in Sephardi Jewish women. This supports changing the paradigm to population-based BRCA testing in the Jewish population, regardless of Ashkenazi/Sephardi ancestry.
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Affiliation(s)
- Shreeya Patel
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - D Gareth Evans
- Centre for Genomic Medicine, Division of Evolution and Genomic Science, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Clare Turnbull
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Antonis C Antoniou
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, United Kingdom
| | - Usha Menon
- Gynaecological Cancer Research Centre, Department of Women's Cancer, Institute for Women's Health, University College London, London, United Kingdom
| | - Ian Jacobs
- University of New South Wales, Sydney, New South Wales, Australia
| | - Ranjit Manchanda
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom; Gynaecological Cancer Research Centre, Department of Women's Cancer, Institute for Women's Health, University College London, London, United Kingdom; Department of Gynaecological Oncology, Barts Health National Health Service Trust, Royal London Hospital, London, United Kingdom.
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Piszczek C, Ma J, Gould CH, Tseng P. Cancer Risk-Reducing Opportunities in Gynecologic Surgery. J Minim Invasive Gynecol 2017; 25:1179-1193. [PMID: 29097232 DOI: 10.1016/j.jmig.2017.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/20/2017] [Accepted: 10/21/2017] [Indexed: 12/16/2022]
Abstract
This review article discusses cancer risk-reducing opportunities in gynecologic surgery. We cover strategies to reduce ovarian and uterine cancer risk by presenting general practice guidelines and expanding on the literature behind clinical decision points. We address populations of women at increased hereditary risk and those at population risk. We specifically discuss risk-reducing salpingo-oophorectomy, prophylactic salpingectomy with delayed oophorectomy, concomitant hysterectomy, opportunistic salpingectomy, bilateral tubal ligation, and hysterectomy. For clinical scenarios in which data are limited or conflicting, we detail the studies on which clinicians' decisions hinge to allow the reader to weigh the available evidence.
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Affiliation(s)
- Carolyn Piszczek
- Division of Women's Services, Legacy Health System, Portland, Oregon.
| | - Jun Ma
- Divisions of Gynecologic Oncology, Legacy Medical Group, Portland, Oregon
| | - Claire H Gould
- Advanced Gynecology, Legacy Medical Group, Portland, Oregon
| | - Paul Tseng
- Divisions of Gynecologic Oncology, Legacy Medical Group, Portland, Oregon
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Manchanda R, Patel S, Antoniou AC, Levy-Lahad E, Turnbull C, Evans DG, Hopper JL, Macinnis RJ, Menon U, Jacobs I, Legood R. Cost-effectiveness of population based BRCA testing with varying Ashkenazi Jewish ancestry. Am J Obstet Gynecol 2017; 217:578.e1-578.e12. [PMID: 28690137 DOI: 10.1016/j.ajog.2017.06.038] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/22/2017] [Accepted: 06/30/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Population-based BRCA1/BRCA2 testing has been found to be cost-effective compared with family history-based testing in Ashkenazi-Jewish women were >30 years old with 4 Ashkenazi-Jewish grandparents. However, individuals may have 1, 2, or 3 Ashkenazi-Jewish grandparents, and cost-effectiveness data are lacking at these lower BRCA prevalence estimates. We present an updated cost-effectiveness analysis of population BRCA1/BRCA2 testing for women with 1, 2, and 3 Ashkenazi-Jewish grandparents. STUDY DESIGN Decision analysis model. METHODS Lifetime costs and effects of population and family history-based testing were compared with the use of a decision analysis model. 56% BRCA carriers are missed by family history criteria alone. Analyses were conducted for United Kingdom and United States populations. Model parameters were obtained from the Genetic Cancer Prediction through Population Screening trial and published literature. Model parameters and BRCA population prevalence for individuals with 3, 2, or 1 Ashkenazi-Jewish grandparent were adjusted for the relative frequency of BRCA mutations in the Ashkenazi-Jewish and general populations. Incremental cost-effectiveness ratios were calculated for all Ashkenazi-Jewish grandparent scenarios. Costs, along with outcomes, were discounted at 3.5%. The time horizon of the analysis is "life-time," and perspective is "payer." Probabilistic sensitivity analysis evaluated model uncertainty. RESULTS Population testing for BRCA mutations is cost-saving in Ashkenazi-Jewish women with 2, 3, or 4 grandparents (22-33 days life-gained) in the United Kingdom and 1, 2, 3, or 4 grandparents (12-26 days life-gained) in the United States populations, respectively. It is also extremely cost-effective in women in the United Kingdom with just 1 Ashkenazi-Jewish grandparent with an incremental cost-effectiveness ratio of £863 per quality-adjusted life-years and 15 days life gained. Results show that population-testing remains cost-effective at the £20,000-30000 per quality-adjusted life-years and $100,000 per quality-adjusted life-years willingness-to-pay thresholds for all 4 Ashkenazi-Jewish grandparent scenarios, with ≥95% simulations found to be cost-effective on probabilistic sensitivity analysis. Population-testing remains cost-effective in the absence of reduction in breast cancer risk from oophorectomy and at lower risk-reducing mastectomy (13%) or risk-reducing salpingo-oophorectomy (20%) rates. CONCLUSION Population testing for BRCA mutations with varying levels of Ashkenazi-Jewish ancestry is cost-effective in the United Kingdom and the United States. These results support population testing in Ashkenazi-Jewish women with 1-4 Ashkenazi-Jewish grandparent ancestry.
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Affiliation(s)
- Ranjit Manchanda
- 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; 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, Barts Cancer Institute, Queen Mary University of London, London, UK; 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, Worts Causeway, Cambridge, UK
| | - Ephrat Levy-Lahad
- Medical Genetics Institute, Shaare Zedek Hospital, Jerusalem, Israel
| | - Clare Turnbull
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | - D Gareth Evans
- Centre for Genomic Medicine, Division of Evolution and Genomic science, University of Manchester, Manchester, UK
| | - John L Hopper
- Centre for Epidemiology & Biostatistics, Melbourne School of Population & Global Health, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Victoria, Australia
| | - Robert J Macinnis
- Cancer Epidemiology & Intelligence Division, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Usha Menon
- Gynaecological Cancer Research Centre, Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
| | - Ian Jacobs
- University of New South Wales, UNSW Sydney NSW
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Paterson R, Phillips KA. Genetic testing in women with breast cancer: implications for treatment. Expert Rev Anticancer Ther 2017; 17:991-1002. [PMID: 28853307 DOI: 10.1080/14737140.2017.1374175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Mutations in either the BRCA1 or BRCA2 genes are responsible for approximately 42,000 cases of breast cancer annually. Identifying these germline mutations in a woman with breast cancer is important because it can influence her immediate and long-term management and has important implications for other family members. Areas covered: This review highlights how treatment-focussed genetic testing for BRCA1 and BRCA2 mutations can potentially influence cancer treatment and secondary prevention decisions in women with breast cancer. Expert commentary: Testing women with breast cancer for BRCA1 and BRCA2 germline mutations has the potential to decrease cancer burden and improve cancer outcomes. It can help optimise surgical and systemic therapy approaches. Clinicians should actively consider whether genetic testing is appropriate for each woman with breast cancer, and if so should instigate it early in the treatment trajectory when it can most influence cancer care.
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Affiliation(s)
- Robin Paterson
- a Australia and New Zealand Breast Cancer Trials Group , Newcastle , Australia.,b School of Medicine and Public Health , University of Newcastle , Newcastle , Australia
| | - Kelly-Anne Phillips
- a Australia and New Zealand Breast Cancer Trials Group , Newcastle , Australia.,c Division of Cancer Medicine , Peter MacCallum Cancer Centre , Melbourne , Australia.,d Sir Peter MacCallum Department of Oncology , University of Melbourne , Parkville , Australia.,e School of Population and Global Health , University of Melbourne , Carlton , Australia
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Jatoi I, Benson JR. Management of women with a hereditary predisposition for breast cancer. Future Oncol 2016; 12:2277-88. [DOI: 10.2217/fon-2016-0186] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Women with a hereditary breast cancer predisposition have three management options: screening, chemoprevention (risk-reducing medication) and risk-reducing surgery. However, no randomized trials have addressed the effect of these strategies in mutation carriers. In the general population, randomized trials failed to demonstrate a benefit for screening in premenopausal women. Moreover, although chemoprevention reduces breast cancer incidence in high-risk populations, this benefit is potentially confined to estrogen receptor-positive tumors. Finally, observational studies suggest that prophylactic mastectomy and even prophylactic salpingo-ophorectomy reduces breast cancer risk in BRCA mutation carriers, but there are systematic biases associated with such studies. Therefore, women with a hereditary predisposition for breast cancer should be informed of the three risk-reducing strategies, and that their benefits are not fully understood.
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Affiliation(s)
- Ismail Jatoi
- Division of Surgical Oncology & Endocrine Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - John R Benson
- Addenbrookes Hospital, Cambridge University, Cambridge, UK
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Tran G, Helm M, Litton J. Current Approach to Breast Cancer Risk Reduction for Women with Hereditary Predispositions to Breast Cancer. CURRENT BREAST CANCER REPORTS 2016. [DOI: 10.1007/s12609-016-0220-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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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.
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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
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