title: Mortality reduction and cost-effectiveness of performing hysterectomy at the time of risk-reducing salpingo-oophorectomy for prophylaxis against serous/serous-like uterine cancers in BRCA1 mutation carriers.
abstract: To estimate the survival benefit and cost-effectiveness of performing hysterectomy during risk-reducing salpingo-oophorectomy (RRSO) for BRCA1 mutation carriers.
  
  
  
  Based on a recent prospective cohort study indicating an elevated incidence of serous/serous-like uterine cancers among BRCA1 mutation carriers, we constructed a modified Markov decision model from a payer perspective to inform decisions about performance of hysterectomy during RRSO at age 40. We assumed patients had previously undergone a risk-reducing mastectomy and had a residual risk of death from breast or ovarian cancer. Disease-specific survival, age-adjusted competing hysterectomy rates, and deaths from other causes were incorporated. Costs of risk-reducing surgery, competing hysterectomy, and care for serous/serous-like uterine cancer were included.
  
  
  
  A 40year old woman who undergoes RRSO+Hysterectomy gains 4.9 additional months of overall survival (40.38 versus 39.97 undiscounted years) compared to RRSO alone. The lifetime probabilities of developing or dying from serous/serous-like uterine cancer in the RRSO group are 3.5% and 2%, respectively. The RRSO alone strategy has an average cost of $9013 compared to $8803 for RRSO+Hysterectomy, and is dominated (less effective and more costly) when compared to RRSO+Hysterectomy. In an alternative analysis, delayed hysterectomy remains a cost-effective prevention strategy with an ICER of less than $100,000/year for up to 25years following RRSO at age 40.
  
  
  
  The addition of hysterectomy to RRSO in a 40year old BRCA1 mutation carrier results in a mean gain of 4.9 additional months of life and is cost-effective.
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, United States; Department of Obstetrics and Gynecology, Duke University Medical Center, United States; Duke Cancer Institute, Durham, NC 27710, United States. Electronic address: havri001@mc.duke.edu.
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Havrilesky
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, United States; Department of Obstetrics and Gynecology, Duke University Medical Center, United States.
authors.forename: Haley A
authors.initials: HA
authors.lastname: Moss
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, United States; Duke Cancer Institute, Durham, NC 27710, United States.
authors.forename: Junzo
authors.initials: J
authors.lastname: Chino
authors.affiliation: Division of Clinical and Epidemiological Research, Department of Obstetrics and Gynecology, Duke University, United States; Department of Obstetrics and Gynecology, Duke University Medical Center, United States; Duke Cancer Institute, Durham, NC 27710, United States.
authors.forename: Evan R
authors.initials: ER
authors.lastname: Myers
authors.affiliation: Duke Cancer Institute, Durham, NC 27710, United States.
authors.forename: Noah D
authors.initials: ND
authors.lastname: Kauff
mesh_terms: D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D018284:Cystadenocarcinoma, Serous / Q000191:economics / Q000235:genetics / Q000401:mortality / Q000517:prevention & control*; D005260:Female; D019398:Genes, BRCA1; D018095:Germ-Line Mutation; D006801:Humans; D007044:Hysterectomy / Q000191:economics* / Q000379:methods; D008390:Markov Chains; D008875:Middle Aged; D015233:Models, Statistical; D010052:Ovariectomy / Q000191:economics / Q000379:methods; D065286:Prophylactic Surgical Procedures / Q000191:economics* / Q000379:methods; D014481:United States / Q000453:epidemiology; D014594:Uterine Neoplasms / Q000191:economics / Q000235:genetics / Q000401:mortality / Q000517:prevention & control*
keywords: BRCA1; Cost-effectiveness; Hysterectomy; Risk-reducing salpingo-oophorectomy