title: Long-term consequences of ovarian ablation for premenopausal breast cancer.
abstract: The TEXT and SOFT trials concluded that an aromatase inhibitor (AI) with ovarian ablation (OA) yields a higher 5-year disease-free survival than tamoxifen alone in premenopausal ER+ high-risk early breast cancer. However, the long-term health consequences and costs of OA, either by GnRH agonist or oophorectomy, have not been evaluated. The objective was to conduct a cost-effectiveness analysis comparing tamoxifen to OA with AI. Markov Monte Carlo simulation model estimated the costs and benefits of 3 endocrine strategies: (1) tamoxifen; (2) GnRH agonist with AI (GnRHa-AI); (3) bilateral salpingo-oophorectomy with AI (BSO-AI). Effectiveness was measured in life expectancy gain (years), and costs were averaged over a lifetime (USD 2015). Adverse events and deaths from each strategy were modeled in the United States population over a time horizon of 40 years. For women without prior chemotherapy (low-risk), tamoxifen alone was more effective (18.03 years) and less costly ($1566) than GnRHa-AI (17.66 years, $93,692) or BSO-AI (17.63 years, $25,892). For those with prior chemotherapy (high-risk), BSO-AI was more costly but more effective (16.78 years, $25,368) than tamoxifen alone (16.55 years, $1523) with an ICER of $102,290, while GnRHa-AI yielded an ICER of $443,376. The simulation estimated 787 and 577 deaths attributable to OA among 9320 high-risk women after BSO-AI and GnRHa-AI, respectively. There may be a role for ovarian ablation in premenopausal women with ER+ high-risk early breast cancer; however, this analysis raises concerns about the long-term health consequences of ovarian ablation and the potential effects on overall survival.
authors.affiliation: Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada. Janice.Kwon@vch.ca.|Division of Gynecologic Oncology, University of British Columbia, 2775 Laurel Street, 6th Floor, Vancouver, BC, V5Z 1M9, Canada. Janice.Kwon@vch.ca.
authors.forename: Janice S
authors.initials: JS
authors.lastname: Kwon
authors.affiliation: Department of Medical Oncology, BC Cancer Agency, Vancouver, BC, Canada.
authors.forename: Gary
authors.initials: G
authors.lastname: Pansegrau
authors.affiliation: Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Melica
authors.initials: M
authors.lastname: Nourmoussavi
authors.affiliation: Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Hammond
authors.affiliation: Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Carey
mesh_terms: D018931:Antineoplastic Agents, Hormonal / Q000191:economics* / Q000627:therapeutic use; D001943:Breast Neoplasms / Q000188:drug therapy*; D003362:Cost-Benefit Analysis; D018572:Disease-Free Survival; D005260:Female; D017273:Goserelin / Q000191:economics* / Q000627:therapeutic use; D006801:Humans; D008390:Markov Chains; D008875:Middle Aged; D018803:Models, Economic; D010052:Ovariectomy / Q000191:economics*; D017697:Premenopause; D016019:Survival Analysis; D013629:Tamoxifen / Q000191:economics* / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D018931:Antineoplastic Agents, Hormonal; D013629:Tamoxifen; D017273:Goserelin
keywords: Breast cancer; Long-term health consequences; Ovarian ablation; Overall survival; Premenopausal