Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH.
Department of Obstetrics and Gynecology, Providence Saint John's Health Center, Santa Monica, CA.
Am J Obstet Gynecol. 2022 Aug;227(2):311.e1-311.e7. doi: 10.1016/j.ajog.2022.04.043. Epub 2022 Apr 28.
The lifetime risk of ovarian cancer is 1.9% among women with endometriosis compared with 1.3% among the general population. When an asymptomatic endometrioma is incidentally discovered on imaging, gynecologists must weigh the procedural complications and the potential for subsequent surgical menopause against future ovarian pathology or cancer.
We aimed to determine if performing unilateral salpingo-oophorectomy is a more cost-effective strategy for the prevention of death than surveillance for asymptomatic endometriomas.
We created a cost-effectiveness model using TreeAge Pro (TreeAge Software Inc; Williamstown, MA) with a lifetime horizon. Our hypothetical cohort included premenopausal patients with 2 ovaries who did not desire fertility. Those diagnosed with asymptomatic endometrioma underwent either unilateral salpingo-oophorectomy or surveillance (ultrasound 6-12 weeks after diagnosis, then annually). Our primary effectiveness outcome was mortality, including death from ovarian cancer or surgery and all-cause mortality related to surgical menopause (± hormone replacement therapy) if the contralateral ovary is removed. We modeled the probabilities of surgical complications, occult malignancy, development of contralateral adnexal pathology, surgical menopause, use of hormone replacement therapy, and development of ovarian cancer. The costs included surgical procedures, complications, ultrasound surveillance, hormone therapy, and treatment of ovarian cancer, with information gathered from Medicare reimbursement data and published literature. Cost-effectiveness was determined using the incremental cost-effectiveness ratio of Δ costs / Δ deaths with a willingness-to-pay threshold of $11.6 million as the value of a statistical life. Multiple 1-way sensitivity analyses were performed to evaluate model robustness.
Our model demonstrated that unilateral salpingo-oophorectomy is associated with improved outcomes compared with surveillance, with fewer deaths (0.28% vs 1.50%) and fewer cases of ovarian cancer (0.42% vs 2.96%). However, it costs more than sonographic surveillance at $6403.43 vs $5381.39 per case of incidental endometrioma. The incremental cost-effectiveness ratio showed that unilateral salpingo-oophorectomy costs $83,773.77 per death prevented and $40,237.80 per case of ovarian cancer prevented. As both values were well below the willingness-to-pay threshold, unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy. If unilateral salpingo-oophorectomy were chosen over surveillance for premenopausal patients with incidental endometriomas, 1 diagnosis of ovarian cancer would be prevented in every 40 patients and 1 death averted in every 82 patients. We performed 1-way sensitivity analyses for all input variables and determined that there were no reasonable inputs that would alter our conclusions.
Unilateral salpingo-oophorectomy is cost-effective and is the preferred strategy compared with surveillance for the management of incidental endometrioma in a premenopausal patient not desiring fertility. It incurs fewer deaths and fewer cases of ovarian cancer with costs below the national willingness-to-pay thresholds.
与一般人群相比，患有子宫内膜异位症的女性一生中患卵巢癌的风险为 1.9%。当在影像学检查中偶然发现无症状的卵巢子宫内膜异位囊肿时，妇科医生必须权衡手术并发症的风险和随后手术绝经的可能性，与未来的卵巢病理或癌症作斗争。
我们旨在确定对无症状卵巢子宫内膜异位囊肿进行单侧输卵管卵巢切除术是否比监测更能有效地预防死亡。
我们使用 TreeAge Pro（TreeAge Software Inc；马萨诸塞州威廉斯敦）创建了一个具有终生时间范围的成本效益模型。我们的假设队列包括 2 个卵巢且不希望生育的绝经前患者。那些被诊断为无症状卵巢子宫内膜异位囊肿的患者要么接受单侧输卵管卵巢切除术，要么接受监测（诊断后 6-12 周进行超声检查，然后每年进行一次）。我们的主要有效性结果是死亡率，包括卵巢癌或手术导致的死亡，以及如果切除对侧卵巢，与手术绝经相关的全因死亡率（±激素替代疗法）。我们对手术并发症、隐匿性恶性肿瘤、对侧附件病变的发展、手术绝经、激素替代疗法的使用和卵巢癌的发展进行了建模。成本包括手术程序、并发症、超声监测、激素治疗和卵巢癌治疗，信息来自医疗保险报销数据和已发表的文献。使用增量成本效益比（Δ成本/Δ死亡）来确定成本效益，愿意支付的阈值为 1160 万美元，作为统计生命的价值。进行了多次 1 次单因素敏感性分析，以评估模型的稳健性。
我们的模型表明，与监测相比，单侧输卵管卵巢切除术可改善预后，死亡率更低（0.28%对 1.50%），卵巢癌发病率更低（0.42%对 2.96%）。然而，它比超声监测更昂贵，每例偶然发现的子宫内膜异位囊肿的费用为 6403.43 美元，而超声监测的费用为 5381.39 美元。增量成本效益比显示，单侧输卵管卵巢切除术每预防 1 例死亡的成本为 83773.77 美元，每预防 1 例卵巢癌的成本为 40237.80 美元。由于这两个值都远低于愿意支付的阈值，因此单侧输卵管卵巢切除术具有成本效益，是首选策略。如果选择单侧输卵管卵巢切除术而不是监测对有偶然发现的子宫内膜异位囊肿的绝经前患者进行治疗，则每 40 例患者中可预防 1 例卵巢癌的诊断，每 82 例患者中可预防 1 例死亡。我们对所有输入变量进行了 1 次单因素敏感性分析，并确定没有合理的输入会改变我们的结论。
与监测相比，单侧输卵管卵巢切除术在管理绝经前且不希望生育的女性偶然发现的子宫内膜异位囊肿方面具有成本效益，且成本低于国家愿意支付的阈值，可降低死亡率和卵巢癌发病率。
