Dilley Sarah E, Havrilesky Laura J, Bakkum-Gamez Jamie, Cohn David E, Michael Straughn J, Caughey Aaron B, Rodriguez Maria I
Department of Obstetrics and Gynecology, Oregon Health and Science University, Mail Code L-466, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, United States.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University, 20 Duke Medicine Cir, Durham, NC 27710, United States.
Gynecol Oncol. 2017 Aug;146(2):373-379. doi: 10.1016/j.ygyno.2017.05.034. Epub 2017 Jun 1.
Data suggesting a link between the fallopian tube and ovarian cancer have led to an increase in rates of salpingectomy at the time of pelvic surgery, a practice known as opportunistic salpingectomy (OS). However, the potential benefits, risks and costs for this new practice are not well established. Our objective was to assess the cost-effectiveness of opportunistic salpingectomy at the time of laparoscopic permanent contraception or hysterectomy for benign indications.
We created two models to compare the cost-effectiveness of salpingectomy versus usual care. The hypothetical study population is 50,000 women aged 45 undergoing laparoscopic hysterectomy with ovarian preservation for benign indications, and 300,000 women aged 35 undergoing laparoscopic permanent contraception. SEER data were used for probabilities of ovarian cancer cases and deaths. The ovarian cancer risk reduction, complication rates, utilities and associated costs were obtained from published literature. Sensitivity analyses and Monte Carlo simulation were performed, and incremental cost-effectiveness ratios (ICERs) were calculated to determine the cost per quality adjusted life year (QALY) gained.
In the laparoscopic hysterectomy cohort, OS is cost saving and would yield $23.9 million in health care dollars saved. In the laparoscopic permanent contraception cohort, OS is cost-effective with an ICER of $31,432/QALY compared to tubal ligation, and remains cost-effective as long as it reduces ovarian cancer risk by 54%. Monte Carlo simulation demonstrated cost-effectiveness with hysterectomy and permanent contraception in 62.3% and 55% of trials, respectively.
Opportunistic salpingectomy for low-risk women undergoing pelvic surgery may be a cost-effective strategy for decreasing ovarian cancer risk at time of hysterectomy or permanent contraception. In our model, salpingectomy was cost-effective with both procedures, but the advantage greater at time of hysterectomy.
有数据表明输卵管与卵巢癌之间存在联系，这导致盆腔手术时输卵管切除术的比例有所增加，这种做法被称为机会性输卵管切除术（OS）。然而，这种新做法的潜在益处、风险和成本尚未明确。我们的目的是评估在腹腔镜下进行永久性避孕或因良性指征行子宫切除术时进行机会性输卵管切除术的成本效益。
我们创建了两个模型来比较输卵管切除术与常规治疗的成本效益。假设的研究人群为50000名45岁因良性指征行保留卵巢的腹腔镜子宫切除术的女性，以及300000名35岁行腹腔镜永久性避孕的女性。监测、流行病学与最终结果（SEER）数据用于卵巢癌病例和死亡的概率。卵巢癌风险降低、并发症发生率、效用值及相关成本均来自已发表的文献。进行了敏感性分析和蒙特卡洛模拟，并计算了增量成本效益比（ICER），以确定每获得一个质量调整生命年（QALY）的成本。
在腹腔镜子宫切除术队列中，机会性输卵管切除术可节省成本，可节省2390万美元的医疗费用。在腹腔镜永久性避孕队列中，与输卵管结扎相比，机会性输卵管切除术具有成本效益，ICER为每QALY 31432美元，只要能将卵巢癌风险降低54%，就仍具有成本效益。蒙特卡洛模拟显示，在分别62.3%和55%的试验中，子宫切除术和永久性避孕采用机会性输卵管切除术具有成本效益。
对于接受盆腔手术的低风险女性，机会性输卵管切除术可能是在子宫切除术或永久性避孕时降低卵巢癌风险的一种具有成本效益的策略。在我们的模型中，两种手术方式采用输卵管切除术均具有成本效益，但在子宫切除术时优势更大。
