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Sundell M, Brynhildsen J, Fredrikson M, Hoffmann M, Spetz Holm AC. Insufficient use of menopausal hormone therapy in Swedish women with early or premature menopause caused by bilateral oophorectomy: a register-based study. BJOG 2024; 131:500-507. [PMID: 37667667 DOI: 10.1111/1471-0528.17647] [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: 06/05/2023] [Revised: 08/14/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE To investigate the use of menopausal hormone therapy (MHT) in premenopausal women after bilateral oophorectomy. DESIGN Retrospective register-based cohort study. SETTING Sweden. POPULATION Swedish women aged 35-44 years without malignancy who underwent bilateral oophorectomy in 2005-2020 were identified using The Swedish National Quality Register of Gynaecological Surgery (GynOp). METHODS Data from GynOp were cross-linked with data on dispensed drugs extracted from the Swedish Prescribed Drug Register. MAIN OUTCOME MEASURES Proportion of women dispensed MHT at least once within 1 year after surgery. Repeated treatment episodes were defined, and the proportion of 'person time' covered by dispensations was analysed. RESULTS In total, 1231 of all women (n = 1706) were dispensed MHT at some point after surgery, with 1177 women dispensed MHT within 1 year. This proportion increased from 64% in 2005 to 84% in 2019 (p < 0.001). In the total population, 4537 'treatment years' transpired, corresponding to 43% of the mean time covered. In women dispensed MHT within 1 year, the proportion of time covered was 63%. CONCLUSIONS Only 69% of all women without malignancy of any kind who underwent bilateral oophorectomy were dispensed MHT within 1 year after surgery, and the duration of treatment was limited. It is important to study further the reasons behind the low dispensation rate in this group to increase adherence to current treatment guidelines, improve quality of life, and avoid increased morbidity and mortality.
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Affiliation(s)
- Micaela Sundell
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Obstetrics and Gynaecology, Kalmar County Hospital, Kalmar, Sweden
| | - Jan Brynhildsen
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mats Fredrikson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mikael Hoffmann
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- The NEPI Foundation, Stockholm, Sweden
| | - Anna-Clara Spetz Holm
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Obstetrics and Gynaecology, Linköping University Hospital, Linköping, Sweden
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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.
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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
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Guo F, Adekanmbi V, Hsu CD, Berenson AB, Kuo YF, Shih YCT. Cost-Effectiveness of Population-Based Multigene Testing for Breast and Ovarian Cancer Prevention. JAMA Netw Open 2024; 7:e2356078. [PMID: 38353949 PMCID: PMC10867683 DOI: 10.1001/jamanetworkopen.2023.56078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/21/2023] [Indexed: 02/16/2024] Open
Abstract
Importance The current method of BRCA testing for breast and ovarian cancer prevention, which is based on family history, often fails to identify many carriers of pathogenic variants. Population-based genetic testing offers a transformative approach in cancer prevention by allowing for proactive identification of any high-risk individuals and enabling early interventions. Objective To assess the lifetime incremental effectiveness, costs, and cost-effectiveness of population-based multigene testing vs family history-based testing. Design, Setting, and Participants This economic evaluation used a microsimulation model to assess the cost-effectiveness of multigene testing (BRCA1, BRCA2, and PALB2) for all women aged 30 to 35 years compared with the current standard of care that is family history based. Carriers of pathogenic variants were offered interventions, such as magnetic resonance imaging with or without mammography, chemoprevention, or risk-reducing mastectomy and salpingo-oophorectomy, to reduce cancer risk. A total of 2000 simulations were run on 1 000 000 women, using a lifetime time horizon and payer perspective, and costs were adjusted to 2022 US dollars. This study was conducted from September 1, 2020, to December 15, 2023. Main Outcomes and Measures The main outcome measure was the incremental cost-effectiveness ratio (ICER), quantified as cost per quality-adjusted life-year (QALY) gained. Secondary outcomes included incremental cost, additional breast and ovarian cancer cases prevented, and excess deaths due to coronary heart disease (CHD). Results The study assessed 1 000 000 simulated women aged 30 to 35 years in the US. In the base case, population-based multigene testing was more cost-effective compared with family history-based testing, with an ICER of $55 548 per QALY (95% CI, $47 288-$65 850 per QALY). Population-based multigene testing would be able to prevent an additional 1338 cases of breast cancer and 663 cases of ovarian cancer, but it would also result in 69 cases of excess CHD and 10 excess CHD deaths per million women. The probabilistic sensitivity analyses show that the probability that population-based multigene testing is cost-effective was 100%. When the cost of the multigene test exceeded $825, population-based testing was no longer cost-effective (ICER, $100 005 per QALY; 95% CI, $87 601-$11 6323). Conclusions and Relevance In this economic analysis of population-based multigene testing, population-based testing was a more cost-effective strategy for the prevention of breast cancer and ovarian cancer when compared with the current family history-based testing strategy at the $100 000 per QALY willingness-to-pay threshold. These findings support the need for more comprehensive genetic testing strategies to identify pathogenic variant carriers and enable informed decision-making for personalized risk management.
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Affiliation(s)
- Fangjian Guo
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston
- Center for Interdisciplinary Research in Women’s Health, The University of Texas Medical Branch at Galveston, Galveston
| | - Victor Adekanmbi
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston
- Center for Interdisciplinary Research in Women’s Health, The University of Texas Medical Branch at Galveston, Galveston
| | - Christine D. Hsu
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston
- Center for Interdisciplinary Research in Women’s Health, The University of Texas Medical Branch at Galveston, Galveston
| | - Abbey B. Berenson
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston
- Center for Interdisciplinary Research in Women’s Health, The University of Texas Medical Branch at Galveston, Galveston
| | - Yong-Fang Kuo
- Center for Interdisciplinary Research in Women’s Health, The University of Texas Medical Branch at Galveston, Galveston
- Department of Biostatistics and Data Science, The University of Texas Medical Branch at Galveston, Galveston
- Office of Biostatistics, University of Texas Medical Branch at Galveston, Galveston
| | - Ya-Chen Tina Shih
- Program in Cancer Health Economics Research, Jonsson Comprehensive Cancer Center, and Department of Radiation Oncology, School of Medicine, University of California, Los Angeles
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Kim S, Kim H, Lee I, Choi E, Baek J, Lee J, Kim HR, Yun BH, Choi YS, Seo SK. Effects of Hormone Replacement Therapy on Bone Mineral Density in Korean Adults With Turner Syndrome. J Korean Med Sci 2024; 39:e9. [PMID: 38193328 PMCID: PMC10782041 DOI: 10.3346/jkms.2024.39.e9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/16/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Turner syndrome (TS) is a common chromosomal abnormality, which is caused by loss of all or part of one X chromosome. Hormone replacement therapy in TS is important in terms of puberty, growth and prevention of osteoporosis however, such a study has never been conducted in Korea. Therefore, the purpose of our study was to determine relationship between the starting age, duration of estrogen replacement therapy (ERT) in TS and develop a hormone replacement protocol suitable for the situation in Korea. METHODS This is retrospective study analyzed the medical records in TS patients treated at the Severance hospital, Yonsei University College of Medicine, Seoul, Korea from 1997 to 2019. Total of 188 subjects who had received a bone density test at least once were included in the study. Korean National Health and Nutrition Examination Survey (KNHANES) was used for achieving bone mineral density (BMD) of normal control group. Student's t-test, Mann-Whitney U test, ANOVA and correlation analysis were performed using SPSS 18.0. RESULTS Each BMD measurement was significantly lower in women with TS than in healthy Korean women. Early start and longer duration of ERT is associated with higher lumbar spine BMD but not femur neck BMD. Femur neck BMD, but not lumbar spine BMD was significantly higher in women with mosaicism than 45XO group. CONCLUSION Early onset and appropriate duration of hormone replacement therapy is important for increasing bone mineral density in patients with Turner syndrome. Also, ERT affects differently to TS patients according to mosaicism.
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Affiliation(s)
- SunYoung Kim
- Dream Foret Obstetrics and Gynecology, Jeju, Korea
| | - Heeyon Kim
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Inha Lee
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Euna Choi
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - JinKyung Baek
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jaekyung Lee
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Hae-Rim Kim
- Department of Statistics, University of Seoul, Seoul, Korea
| | - Bo Hyon Yun
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Young Sik Choi
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Seok Kyo Seo
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Korea.
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Techatraisak K, Rattanachaiyanont M, Tanmahasamut P, Indhavivadhana S, Wongwananuruk T, Jirakittidul P. Impact of Global Consensus Statement on compliance with hormonal therapy for surgical menopause. Climacteric 2022; 25:300-305. [PMID: 34726130 DOI: 10.1080/13697137.2021.1978424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Initiation of and compliance with menopausal hormonal therapy (MHT) have been dropping due to the 2002 Women's Health Initiative (WHI) publication. We evaluated the change in practice of MHT for surgical menopause after implementing the 2013 'Global Consensus Statement on MHT' to our institutional guideline. METHODS A retrospective study was conducted in surgically menopausal women newly registering at the Siriraj Menopause Clinic in a university hospital, Thailand, from 1995 to 2013. The patients were categorized into four groups according to periods of MHT initiation: 1995-1998 (control), 2000-2003 (WHI affected), 2005-2008 (post WHI) and 2010-2013 (Global Consensus Statement affected). Their 3-year compliance with MHT was compared using forward stepwise regression analysis. RESULTS There were 288, 156, 107 and 104 cases in the 1995-1998, 2000-2003, 2005-2008 and 2010-2013 groups. Their mean age at surgery was 42.8 ± 4.7 years. After the first, second and third years, overall compliance was 82.4%, 70.9% and 61.2%, respectively. The 3-year compliance drastically dropped in the 2000-2003 group, and then improved to control level in the 2010-2013 group (51.9% vs. 77.9%, p = 0.035). CONCLUSION The initiation of MHT continuously dropped during 2000-2013; however, compliance with MHT initiated during 2010-2013 improved after implementing the 2013 'Global Consensus Statement on MHT' to our institutional guideline. Each institute should have a strategy to encourage the initiation of and compliance with MHT for surgical menopause to achieve long-term health benefits.
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Affiliation(s)
- K Techatraisak
- Gynecologic Endocrinology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - M Rattanachaiyanont
- Gynecologic Endocrinology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - P Tanmahasamut
- Gynecologic Endocrinology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - S Indhavivadhana
- Gynecologic Endocrinology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - T Wongwananuruk
- Gynecologic Endocrinology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - P Jirakittidul
- Gynecologic Endocrinology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Dixit A, Carden N, Stephens E, Chadwick M, Tamblyn J, Robinson L. Hormone replacement therapy subcutaneous implants for refractory menopause symptoms; the patient's perspective. Post Reprod Health 2022; 28:79-91. [PMID: 35599571 DOI: 10.1177/20533691221097042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE For women with menopause symptoms refractory to standard hormone replacement therapy (HRT) preparations, HRT implants offer an alternative. The primary objective of this study was to evaluate women's perceptions regarding efficacy, tolerability, satisfaction and safety of implant therapy. STUDY DESIGN A single centre service evaluation study performed at Birmingham Women's & Children's Foundation Hospital Trust. An anonymised semi-structured survey link was posted to all women (n = 397) recorded to have received HRT implant(s) at a tertiary Menopause clinic (May 1982 and Dec 2018). Women attending clinic (June 2020 to Sept 2020) were opportunistically invited to complete a written version of the survey. MAIN OUTCOME MEASURES Data collected included demographics, medical and surgical history, therapy duration, type, indication and complications. Climacteric symptoms were assessed using the Greene Climacteric Scale. RESULTS Data was obtained for 119 women. The written survey yielded higher response rates (n = 73, 61.3%). Most respondents were 51-60 years old (n = 51 42.9%) and 87.4% (n = 104) were 'White British'. 70 women used estradiol only implants. 30.1%% (n = 34) of patients reported a low Greene Climacteric Scale score (0-5). Subgroup analysis showed prevalence of sexual dysfunction and vasomotor symptoms across ages. There was a lower prevalence of psychological symptoms amongst ≥51 year olds. High satisfaction rates were reported. CONCLUSIONS Data from a large cohort is presented. Good symptom control, satisfaction and long-term efficacy was demonstrated. This study supports the value of HRT implants for refractory menopause symptoms. A national database of implant users would be a useful tool to record satisfaction scores and adverse events.
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Affiliation(s)
- Anushka Dixit
- College of Medical and Dental Sciences, 150183University of Birmingham, Birmingham, UK
- 2379Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Nikkita Carden
- Specialist Menopause Service, 1729Birmingham Women's & Children's Foundation Hospital Trust, Birmingham, UK
| | - Elaine Stephens
- Specialist Menopause Service, 1729Birmingham Women's & Children's Foundation Hospital Trust, Birmingham, UK
| | - Mark Chadwick
- Specialist Menopause Service, 1729Birmingham Women's & Children's Foundation Hospital Trust, Birmingham, UK
| | - Jennifer Tamblyn
- Specialist Menopause Service, 1729Birmingham Women's & Children's Foundation Hospital Trust, Birmingham, UK
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, 150183University of Birmingham, Birmingham, UK
- Seacroft Hospital, 1729Leeds Teaching Hospitals NHS Trust, Seacroft, Leeds
| | - Lynne Robinson
- Specialist Menopause Service, 1729Birmingham Women's & Children's Foundation Hospital Trust, Birmingham, UK
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Lee J(S, Wasim AM, Karreman E, Al-Hayki M. Hormone therapy use among young cervical cancer patients in Southern Saskatchewan. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:757-761. [DOI: 10.1016/j.jogc.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/26/2022] [Accepted: 03/28/2022] [Indexed: 11/30/2022]
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Cusimano MC, Chiu M, Ferguson SE, Moineddin R, Aktar S, Liu N, Baxter NN. Association of bilateral salpingo-oophorectomy with all cause and cause specific mortality: population based cohort study. BMJ 2021; 375:e067528. [PMID: 34880044 PMCID: PMC8653240 DOI: 10.1136/bmj-2021-067528] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine if bilateral salpingo-oophorectomy, compared with ovarian conservation, is associated with all cause or cause specific death in women undergoing hysterectomy for non-malignant disease, and to determine how this association varies with age at surgery. DESIGN Population based cohort study. SETTING Ontario, Canada from 1 January 1996 to 31 December 2015, and follow-up to 31 December 2017. PARTICIPANTS 200 549 women (aged 30-70 years) undergoing non-malignant hysterectomy, stratified into premenopausal (<45 years), menopausal transition (45-49 years), early menopausal (50-54 years), and late menopausal (≥55 years) groups according to age at surgery; median follow-up was 12 years (interquartile range 7-17). EXPOSURES Bilateral salpingo-oophorectomy versus ovarian conservation. MAIN OUTCOMES MEASURES The primary outcome was all cause death. Secondary outcomes were non-cancer and cancer death. Within each age group, overlap propensity score weighted survival models were used to examine the association between bilateral salpingo-oophorectomy and mortality outcomes, while adjusting for demographic characteristics, gynaecological conditions, and comorbidities. To account for comparisons in four age groups, P<0.0125 was considered statistically significant. RESULTS Bilateral salpingo-oophorectomy was performed in 19%, 41%, 69%, and 81% of women aged <45, 45-49, 50-54, and ≥55 years, respectively. The procedure was associated with increased rates of all cause death in women aged <45 years (hazard ratio 1.31, 95% confidence interval 1.18 to 1.45, P<0.001; number needed to harm 71 at 20 years) and 45-49 years (1.16, 1.04 to 1.30, P=0.007; 152 at 20 years), but not in women aged 50-54 years (0.83, 0.72 to 0.97, P=0.018) or ≥55 years (0.92, 0.82 to 1.03, P=0.16). Findings in women aged <50 years were driven largely by increased non-cancer death. In secondary analyses identifying a possible change in the association between bilateral salpingo-oophorectomy and all cause death with advancing age at surgery, the hazard ratio gradually decreased during the menopausal transition and remained around 1 at all ages thereafter. CONCLUSION In this observational study, bilateral salpingo-oophorectomy at non-malignant hysterectomy appeared to be associated with increased all cause mortality in women aged <50 years, but not in those aged ≥50 years. While caution is warranted when considering bilateral salpingo-oophorectomy in premenopausal women without indication, this strategy for ovarian cancer risk reduction does not appear to be detrimental to survival in postmenopausal women.
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Affiliation(s)
- Maria C Cusimano
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Maria Chiu
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Sarah E Ferguson
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/Sinai Health Systems, Toronto, ON, Canada
| | - Rahim Moineddin
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Suriya Aktar
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Ning Liu
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Nancy N Baxter
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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Techatraisak K, Angsuwathana S, Rattanachaiyanont M, Tanmahasumut P, Indhavivadhana S, Wongwananurak T, Leerasiri P, Jirakittidul P. Compliance and health consequences of menopausal hormonal therapy after surgical menopause: A retrospective study in Thailand. J Obstet Gynaecol Res 2020; 47:208-215. [PMID: 33078538 DOI: 10.1111/jog.14486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 07/01/2020] [Accepted: 08/26/2020] [Indexed: 11/27/2022]
Abstract
AIM To study compliance with menopausal hormonal therapy (MHT) until age ≥ 50 year and health consequences after surgical menopause. METHODS A retrospective cohort study of 1000 consecutive surgically menopausal patients who underwent premenopausal surgery before 50 years of age from benign indications during 1996-2012 was performed. Main outcomes were number in year of MHT compliance and health consequences: hypertension (HT), diabetes mellitus (DM), dyslipidemia (DLP), ischemic heart disease (IHD)/myocardial infarction (MI), venous thromboembolism (VTE), stoke, osteopenia/osteoporosis, cognitive impairment/dementia/Alzheimer's disease (AD) /Parkinsonism and breast/other cancers. The MHT nonuser subgroup served as the control. RESULTS Of the 1000 patients, 855 cases used MHT. The median overall follow-up time from surgery for 145 MHT nonuser patients, 435 MHT users until age <50 year and 420 MHT users until age ≥50 year was 12.0 years. Compliance until age ≥50 year was only 49.1%. For MHT users, the overall median age of stopping MHT was 47.0 year with a median MHT use of 6.0 year. After age adjustment at the time of follow-up of all subgroups by forward stepwise logistic regression analysis, the only significantly different health consequence was osteopenia (32.4%, 10.6% and 21.4% in the MHT nonusers, users until age <50 year and users until age ≥50 year, respectively [P < 0.001]). Prevalence of breast cancer, colon cancer and other cancers were not different among subgroups. CONCLUSION The majority of patients used MHT with low compliance until age ≥50 year. In addition, MHT initiation after surgery possibly prevented osteopenia compared with MHT nonusers.
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Affiliation(s)
- Kitirat Techatraisak
- Department of Obstetrics-Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Surasak Angsuwathana
- Department of Obstetrics-Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Manee Rattanachaiyanont
- Department of Obstetrics-Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Prasong Tanmahasumut
- Department of Obstetrics-Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suchada Indhavivadhana
- Department of Obstetrics-Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanyarat Wongwananurak
- Department of Obstetrics-Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Preeyaporn Jirakittidul
- Department of Obstetrics-Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Manchanda R, Sun L, Patel S, Evans O, Wilschut J, De Freitas Lopes AC, Gaba F, Brentnall A, Duffy S, Cui B, Coelho De Soarez P, Husain Z, Hopper J, Sadique Z, Mukhopadhyay A, Yang L, Berkhof J, Legood R. Economic Evaluation of Population-Based BRCA1/BRCA2 Mutation Testing across Multiple Countries and Health Systems. Cancers (Basel) 2020; 12:cancers12071929. [PMID: 32708835 PMCID: PMC7409094 DOI: 10.3390/cancers12071929] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022] Open
Abstract
Clinical criteria/Family history-based BRCA testing misses a large proportion of BRCA carriers who can benefit from screening/prevention. We estimate the cost-effectiveness of population-based BRCA testing in general population women across different countries/health systems. A Markov model comparing the lifetime costs and effects of BRCA1/BRCA2 testing all general population women ≥30 years compared with clinical criteria/FH-based testing. Separate analyses are undertaken for the UK/USA/Netherlands (high-income countries/HIC), China/Brazil (upper–middle income countries/UMIC) and India (low–middle income countries/LMIC) using both health system/payer and societal perspectives. BRCA carriers undergo appropriate screening/prevention interventions to reduce breast cancer (BC) and ovarian cancer (OC) risk. Outcomes include OC, BC, and additional heart disease deaths and incremental cost-effectiveness ratio (ICER)/quality-adjusted life year (QALY). Probabilistic/one-way sensitivity analyses evaluate model uncertainty. For the base case, from a societal perspective, we found that population-based BRCA testing is cost-saving in HIC (UK-ICER = $−5639/QALY; USA-ICER = $−4018/QALY; Netherlands-ICER = $−11,433/QALY), and it appears cost-effective in UMIC (China-ICER = $18,066/QALY; Brazil-ICER = $13,579/QALY), but it is not cost-effective in LMIC (India-ICER = $23,031/QALY). From a payer perspective, population-based BRCA testing is highly cost-effective in HIC (UK-ICER = $21,191/QALY, USA-ICER = $16,552/QALY, Netherlands-ICER = $25,215/QALY), and it is cost-effective in UMIC (China-ICER = $23,485/QALY, Brazil−ICER = $20,995/QALY), but it is not cost-effective in LMIC (India-ICER = $32,217/QALY). BRCA testing costs below $172/test (ICER = $19,685/QALY), which makes it cost-effective (from a societal perspective) for LMIC/India. Population-based BRCA testing can prevent an additional 2319 to 2666 BC and 327 to 449 OC cases per million women than the current clinical strategy. Findings suggest that population-based BRCA testing for countries evaluated is extremely cost-effective across HIC/UMIC health systems, is cost-saving for HIC health systems from a societal perspective, and can prevent tens of thousands more BC/OC cases.
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Affiliation(s)
- Ranjit Manchanda
- Wolfson Institute for Preventive Medicine, CRUK Barts Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK; (L.S.); (S.P.); (O.E.); (F.G.)
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, UK
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, Faculty of Population Health Sciences, University College London, London WC1V 6LJ, UK
- Correspondence:
| | - Li Sun
- Wolfson Institute for Preventive Medicine, CRUK Barts Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK; (L.S.); (S.P.); (O.E.); (F.G.)
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK; (Z.S.); (R.L.)
| | - Shreeya Patel
- Wolfson Institute for Preventive Medicine, CRUK Barts Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK; (L.S.); (S.P.); (O.E.); (F.G.)
| | - Olivia Evans
- Wolfson Institute for Preventive Medicine, CRUK Barts Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK; (L.S.); (S.P.); (O.E.); (F.G.)
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, UK
| | - Janneke Wilschut
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, Netherlands; (J.W.); (J.B.)
| | - Ana Carolina De Freitas Lopes
- Departamento de Medicina Preventiva, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, 01246903 Sao Paulo, Brazil; (A.C.D.F.L.); (P.C.D.S.)
| | - Faiza Gaba
- Wolfson Institute for Preventive Medicine, CRUK Barts Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK; (L.S.); (S.P.); (O.E.); (F.G.)
- Department of Gynaecological Oncology, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, UK
| | - Adam Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK; (A.B.); (S.D.)
| | - Stephen Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK; (A.B.); (S.D.)
| | - Bin Cui
- School of Public Health, Peking University, Beijing 100191, China; (B.C.); (L.Y.)
| | - Patricia Coelho De Soarez
- Departamento de Medicina Preventiva, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, 01246903 Sao Paulo, Brazil; (A.C.D.F.L.); (P.C.D.S.)
| | - Zakir Husain
- Department of Humanities & Social Sciences, Indian Institute of Technology, Kharagpur, West Bengal 721302, India;
- Department of Economics, Presidency University, Kolkata 700073, India
| | - John Hopper
- Centre for Epidemiology & Biostatistics, Melbourne School of Population & Global Health, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Victoria 3010, Australia;
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK; (Z.S.); (R.L.)
| | - Asima Mukhopadhyay
- Tata Medical Centre, Kolkata, West Bengal 700160, India;
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Li Yang
- School of Public Health, Peking University, Beijing 100191, China; (B.C.); (L.Y.)
| | - Johannes Berkhof
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, Netherlands; (J.W.); (J.B.)
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK; (Z.S.); (R.L.)
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Tamhane N, Imudia AN, Mikhail E. Contemporary management of adnexa at the time of benign hysterectomy: a review of the literature. J OBSTET GYNAECOL 2019; 39:896-902. [PMID: 31303119 DOI: 10.1080/01443615.2019.1581747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Ovarian cancer is the leading cause of Gynecological cancer related mortality in the USA. Due to the absence of an effective screening method, concomitant adnexal management during hysterectomy or other pelvic surgeries is a prime consideration. Bilateral salpingo-oophorectomy (BSO) offers the benefit of eliminating the risk of ovarian cancer however it leads to surgical menopause with unfavourable overall health outcomes. With the latest verification that serous tubal intraepithelial carcinoma detected in the distal fimbriated end of the fallopian tube being the precursor of Type 2 ovarian cancers, there is an increased trend of performing bilateral salpingectomy (BS) as a risk reduction strategy for ovarian cancer. Women with a high risk for ovarian cancer due to familial or genetic mutations and those diagnosed with endometriosis need particular attention while planning adnexal management during hysterectomy. Physician and patient's shared decision-making regarding adnexal management during benign hysterectomy taking into consideration the route of hysterectomy is an important portion of pre-operative planning. The objective of this article is to understand the current trends of BSO and BS during benign hysterectomy and appreciate the pros and cons to aid in pre-operative counselling of patients.
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Affiliation(s)
- Nupur Tamhane
- Department of Obstetrics & Gynecology, Morsani College School of medicine, University of South Florida , Tampa , FL , USA
| | - Anthony N Imudia
- Department of Obstetrics & Gynecology, Morsani College School of medicine, University of South Florida , Tampa , FL , USA
| | - Emad Mikhail
- Department of Obstetrics & Gynecology, Morsani College School of medicine, University of South Florida , Tampa , FL , USA
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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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13
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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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14
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Adelman MR, Sharp HT. Ovarian conservation vs removal at the time of benign hysterectomy. Am J Obstet Gynecol 2018; 218:269-279. [PMID: 28784419 DOI: 10.1016/j.ajog.2017.07.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/14/2017] [Accepted: 07/31/2017] [Indexed: 11/17/2022]
Abstract
Over the last 2 decades, the rate of oophorectomy at the time of hysterectomy in the United States has consistently been between 40-50%. A decline in hormone use has been observed since the release of the principal results of the Women's Health Initiative. Oophorectomy appears to be associated with an increased risk of coronary heart disease, as well as deleterious effects on overall mortality, cognitive functioning, and sexual functioning. Estrogen deficiency from surgical menopause is associated with bone mineral density loss and increased fracture risk. While hormone therapy may mitigate these effects, at no age does there appear to be a survival benefit associated with oophorectomy. Reduction of ovarian cancer risk may be accomplished with salpingectomy at the time of hysterectomy.
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Affiliation(s)
- Marisa R Adelman
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT.
| | - Howard T Sharp
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
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15
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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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16
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Au A, Feher A, McPhee L, Jessa A, Oh S, Einstein G. Estrogens, inflammation and cognition. Front Neuroendocrinol 2016; 40:87-100. [PMID: 26774208 DOI: 10.1016/j.yfrne.2016.01.002] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 01/02/2016] [Accepted: 01/11/2016] [Indexed: 01/15/2023]
Abstract
The effects of estrogens are pleiotropic, affecting multiple bodily systems. Changes from the body's natural fluctuating levels of estrogens, through surgical removal of the ovaries, natural menopause, or the administration of exogenous estrogens to menopausal women have been independently linked to an altered immune profile, and changes to cognitive processes. Here, we propose that inflammation may mediate the relationship between low levels of estrogens and cognitive decline. In order to determine what is known about this connection, we review the literature on the cognitive effects of decreased estrogens due to oophorectomy or natural menopause, decreased estrogens' role on inflammation--both peripherally and in the brain--and the relationship between inflammation and cognition. While this review demonstrates that much is unknown about the intersection between estrogens, cognition, inflammation, we propose that there is an important interaction between these literatures.
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Affiliation(s)
- April Au
- University of Toronto, 100 St. George Street, 4F Sidney Smith Hall, Dept. of Psychology, Toronto, ON M5S 3G3, Canada.
| | - Anita Feher
- University of Toronto, 100 St. George Street, 4F Sidney Smith Hall, Dept. of Psychology, Toronto, ON M5S 3G3, Canada.
| | - Lucy McPhee
- University of Toronto, 100 St. George Street, 4F Sidney Smith Hall, Dept. of Psychology, Toronto, ON M5S 3G3, Canada.
| | - Ailya Jessa
- University of Toronto, 100 St. George Street, 4F Sidney Smith Hall, Dept. of Psychology, Toronto, ON M5S 3G3, Canada.
| | - Soojin Oh
- University of Toronto, 100 St. George Street, 4F Sidney Smith Hall, Dept. of Psychology, Toronto, ON M5S 3G3, Canada.
| | - Gillian Einstein
- University of Toronto, 100 St. George Street, 4F Sidney Smith Hall, Dept. of Psychology, Toronto, ON M5S 3G3, Canada.
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Costs and benefits of opportunistic salpingectomy as an ovarian cancer prevention strategy. Obstet Gynecol 2015; 125:338-345. [PMID: 25568991 DOI: 10.1097/aog.0000000000000630] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To conduct a cost-effectiveness analysis of opportunistic salpingectomy (elective salpingectomy at hysterectomy or instead of tubal ligation). METHODS A Markov Monte Carlo simulation model estimated the costs and benefits of opportunistic salpingectomy in a hypothetical cohort of women undergoing hysterectomy for benign gynecologic conditions or surgical sterilization. The primary outcome measure was the incremental cost-effectiveness ratio. Effectiveness was measured in terms of life expectancy gain. Sensitivity analyses accounted for uncertainty around various parameters. Monte Carlo simulation estimated the number of ovarian cancer cases associated with each strategy in the Canadian population. RESULTS Salpingectomy with hysterectomy was less costly ($11,044.32 ± $1.56) than hysterectomy alone ($11,206.52 ± $29.81) or with bilateral salpingo-oophorectomy ($12,626.84 ± $13.11) but more effective at 21.12 ± 0.02 years compared with 21.10 ± 0.03 and 20.94 ± 0.03 years, representing average gains of 1 week and 2 months, respectively. For surgical sterilization, salpingectomy was more costly ($9,719.52 ± $3.74) than tubal ligation ($9,339.48 ± $26.74) but more effective at 22.45 ± 0.02 years compared with 22.43 ± 0.02 years (average gain of 1 week) with an incremental cost-effectiveness ratio of $27,278 per year of life gained. Our results were stable over a wide range of costs and risk estimates. Monte Carlo simulation predicted that salpingectomy would reduce ovarian cancer risk by 38.1% (95% confidence interval [CI] 36.5-41.3%) and 29.2% (95% CI 28.0-31.4%) compared with hysterectomy alone or tubal ligation, respectively. CONCLUSION Salpingectomy with hysterectomy for benign conditions will reduce ovarian cancer risk at acceptable cost and is a cost-effective alternative to tubal ligation for sterilization. Opportunistic salpingectomy should be considered for all women undergoing these surgical procedures.
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Demirci B, Demir O, Dost T, Birincioglu M. Antioxidative effect of aspirin on vascular function of aged ovariectomized rats. AGE (DORDRECHT, NETHERLANDS) 2014; 36:223-229. [PMID: 23872923 PMCID: PMC3889896 DOI: 10.1007/s11357-013-9569-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 07/12/2013] [Indexed: 06/02/2023]
Abstract
This study investigated the vascular effects of nonsteroidal anti-inflammatory drugs (NSAIDs) in the very late stage of postmenopausal vascular aging and looked for a better choice of anti-inflammatory drug for women in reducing the cardiovascular risk by decreasing the oxidant status in this term. The rat aorta isolated from young and old rats that were treated with either aspirin (10 mg/kg/day) or indomethacin (INDO, 1 mg/kg/day) within last 10 weeks after 16-month overiectomy (OVX) follow-up. Endothelium-dependant acetylcholine (Ach, 0.001-30 μM) and independent sodium nitroprusside (SNP, 0.0001-3 μM) relaxant; α-receptor phenylephrine (PE, 0.001-30 μM) and voltage-dependant high potassium (KCl; 40 mM) contractile responses were assessed. Total oxidant and antioxidant status were measured from the serum samples. Aged OVX rat's both aortic endothelium and smooth muscle relaxation were significantly less than of younger ones, whereas their contractile functions tended to decrease. INDO did not treat the Ach, SNP responses, whereas it increased the PE and KCl contractility. Aspirin improved the relaxation function and antioxidant capacity and decreased the oxidant status. These data demonstrate that even if they are in the very late stage of life and menopause, the analgesic choices could restore the well established endothelial dysfunction, vascular stiffness, and oxidant status.
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Affiliation(s)
- Buket Demirci
- Department of Medical Pharmacology, Adnan Menderes University, Aydin, 09100, Turkey,
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