title: Defining the risk threshold for risk reducing salpingo-oophorectomy for ovarian cancer prevention in low risk postmenopausal women.
abstract: OBJECTIVE
  To define risk thresholds for cost-effectiveness of risk-reducing salpingo-oophorectomy (RRSO) for ovarian cancer (OC) prevention in low/intermediate risk postmenopausal women.
  
  
  METHODS
  A decision-analytic model compares lifetime costs-&-effects of offering 'RRSO' with 'no RRSO' to postmenopausal women ≥50years for different lifetime OC-risk thresholds: 2%, 4%, 5%, 6%, 8% and 10%. Well established data from the literature are used to estimate total costs, effects in terms of Quality-Adjusted-Life-Years(QALYs), cancer incidence, incremental cost-effectiveness ratio(ICER) and impact. Costs are reported at 2012 prices; costs/outcomes discounted at 3.5%. Deterministic/probabilistic sensitivity analysis (PSA) evaluate model uncertainty.
  
  
  RESULTS
  RRSO does not save QALYs and is not cost-effective at the 2% general population lifetime OC-risk. At 4% OC-risk RRSO saves QALYs but is not cost-effective. At risk thresholds ≥5%, RRSO saves more life-years and QALYs and is highly cost-effective. The ICERs for OC-risk levels 5%, 6%, 8% and 10% are £15,247, £9958, £4584, and £1864 respectively. The gain in life-years from RRSO equates to 29.2, 40.1, 62.1 and 80.3days at risk thresholds of 5%, 6%, 8% and 10% respectively. The results are not sensitive to treatment costs of RRSO/OC/cardiovascular events but are sensitive to utility-scores for RRSO. On PSA, 67%, 80%, 84%, 91% and 94% of simulations at risk thresholds of 4%, 5%, 6%, 8% and 10% respectively are cost-effective for RRSO.
  
  
  CONCLUSIONS
  RRSO is highly cost-effective in postmenopausal women aged >50 with ≥5% lifetime OC-risk and increases life-expectancy by ≥29.2days. The results could have significant clinical implications given the improvements in risk prediction and falling costs of genotyping.
authors.affiliation: Department of Gynaecological Oncology, St Bartholomew's Hospital, London, EC1A 7BE, UK; Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, W1T 7DN, UK; Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.
authors.forename: Ranjit
authors.initials: R
authors.lastname: Manchanda
authors.affiliation: Department of Health Services Research and Policy, 15-17 Tavistock Place, London, WC1H 9SH, UK.
authors.forename: Rosa
authors.initials: R
authors.lastname: Legood
authors.affiliation: Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, 48109, USA; Department of Preventive Medicine, USC Keck School of Medicine, University of Southern California, Los Angeles, CA, 90089, USA.
authors.forename: Leigh
authors.initials: L
authors.lastname: Pearce
authors.affiliation: Department of Women's Cancer, EGA Institute for Women's Health, University College London, London, W1T 7DN, UK. Electronic address: u.menon@ucl.ac.uk.
authors.forename: Usha
authors.initials: U
authors.lastname: Menon
mesh_terms: D000368:Aged; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005260:Female; D019398:Genes, BRCA1; D024522:Genes, BRCA2; D005838:Genotype; D017048:Health Care Costs; D006801:Humans; D008875:Middle Aged; D010051:Ovarian Neoplasms / Q000235:genetics / Q000517:prevention & control*; D010052:Ovariectomy / Q000191:economics*; D017698:Postmenopause; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D058994:Salpingectomy / Q000191:economics*
keywords: Cancer prevention; Cost effectiveness; Ovarian neoplasm; QALY; Risk prediction; Risk reducing salpingo-oophorectomy