title: Prophylactic salpingectomy and delayed oophorectomy as an alternative for BRCA mutation carriers.
abstract: OBJECTIVE
  Prophylactic bilateral salpingo-oophorectomy is advised for women with BRCA mutations, but there are adverse consequences of premature menopause. The majority of BRCA-associated ovarian cancers appear to arise in the fallopian tube; therefore, salpingectomy may be an alternative to bilateral salpingo-oophorectomy. We compared the costs and benefits of salpingectomy with bilateral salpingo-oophorectomy among BRCA mutation carriers.
  
  
  METHODS
  We developed a Markov Monte Carlo simulation model to compare three strategies for risk reduction in women with BRCA mutations: 1) bilateral salpingo-oophorectomy; 2) bilateral salpingectomy; and 3) bilateral salpingectomy with delayed oophorectomy. Net health benefits were measured in years-of-life expectancy and quality-adjusted life-year expectancy, and the primary outcome was the incremental cost-effectiveness ratio. The model estimated the number of future breast and ovarian cancers and cardiovascular deaths attributed to premature menopause with each strategy.
  
  
  RESULTS
  Bilateral salpingo-oophorectomy was associated with the lowest cost and highest life expectancy compared with the other two strategies. When quality-of-life measures were included, salpingectomy followed by delayed oophorectomy yielded the highest quality-adjusted life expectancy with incremental cost-effectiveness ratios of $37,805 and $89,680 per quality-adjusted life-year for BRCA1 and BRCA2, respectively, relative to salpingectomy alone. Bilateral salpingo-oophorectomy yielded the lowest number of future breast and ovarian cancers compared with the other two strategies.
  
  
  CONCLUSIONS
  Bilateral salpingo-oophorectomy offers the greatest risk reduction for breast and ovarian cancer among BRCA mutation carriers. However, when considering quality-adjusted life expectancy, bilateral salpingectomy with delayed oophorectomy is a cost-effective strategy and may be an acceptable alternative for those unwilling to undergo bilateral salpingo-oophorectomy.
authors.affiliation: University of British Columbia and BC Cancer Agency, Vancouver, British Columbia, Canada. janice.kwon@vch.ca
authors.forename: Janice S
authors.initials: JS
authors.lastname: Kwon
authors.forename: Anna
authors.initials: A
authors.lastname: Tinker
authors.forename: Gary
authors.initials: G
authors.lastname: Pansegrau
authors.forename: Jessica
authors.initials: J
authors.lastname: McAlpine
authors.forename: Melissa
authors.initials: M
authors.lastname: Housty
authors.forename: Mary
authors.initials: M
authors.lastname: McCullum
authors.forename: C Blake
authors.initials: CB
authors.lastname: Gilks
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000191:economics / Q000235:genetics / Q000517:prevention & control*; D003198:Computer Simulation; D005260:Female; D019398:Genes, BRCA1; D024522:Genes, BRCA2; D006801:Humans; D016462:Mammaplasty / Q000191:economics; D008390:Markov Chains; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D008954:Models, Biological; D009154:Mutation; D010051:Ovarian Neoplasms / Q000191:economics / Q000235:genetics / Q000517:prevention & control*; D010052:Ovariectomy / Q000379:methods*; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D040242:Risk Reduction Behavior; D058994:Salpingectomy / Q000379:methods*; D016896:Treatment Outcome