The cost-effectiveness of opportunistic salpingectomy versus standard tubal ligation at the time of cesarean delivery for ovarian cancer risk reduction

Akila Subramaniam, Brett D Einerson, Christina T Blanchard, Britt K Erickson, Jeff Szychowski, Charles A Leath 3rd, Joseph R Biggio, Warner K Huh, Akila Subramaniam, Brett D Einerson, Christina T Blanchard, Britt K Erickson, Jeff Szychowski, Charles A Leath 3rd, Joseph R Biggio, Warner K Huh

Abstract

Objectives: Opportunistic salpingectomy is a cost-effective strategy recommended for ovarian cancer (OvCa) risk reduction at the time of gynecologic surgery in women who have completed childbearing. We aimed to evaluate the cost-effectiveness of opportunistic salpingectomy compared to standard tubal ligation (TL) during cesarean delivery.

Study design: A cost-effectiveness analysis using decision modeling to compare opportunistic salpingectomy to TL at the time of cesarean using probabilities of procedure completion derived from a trial. Probability and cost inputs were derived from local data and the literature. The primary outcome was the incremental cost-effectiveness ratio (ICER) in 2017 U.S. dollars per quality-adjusted life year (QALY) at a cost-effectiveness threshold of $100,000/QALY. One- and two-way sensitivity analyses were performed for all variables. A probabilistic sensitivity analysis determined the proportion of simulations in which each strategy would be cost-effective.

Results: Opportunistic salpingectomy was cost-effective compared to TL with an ICER of $26,616 per QALY. In 10,000 women desiring sterilization with cesarean, opportunistic salpingectomy would result in 17 fewer OvCa diagnoses, 13 fewer OvCa deaths, and 25 fewer unintended pregnancies compared to TL - with an associated cost increase of $4.7 million. The model was sensitive only to OvCa risk reduction from salpingectomy and TL. Opportunistic salpingectomy was not cost-effective if its cost was >$3163.74 more than TL, if the risk-reduction of salpingectomy was <41%, or if the risk-reduction of TL was >46%. In probabilistic sensitivity analysis opportunistic salpingectomy was cost effective in 75% of simulations.

Conclusions: In women undergoing cesarean with sterilization, opportunistic salpingectomy is likely cost-effective and may be cost-saving in comparison to TL for OvCa risk reduction.

Trial registration: ClinicalTrials.gov NCT02374827.

Keywords: Cesarean delivery; Cost-effectiveness; Ovarian cancer; Salpingectomy; Tubal ligation.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Copyright © 2018 Elsevier Inc. All rights reserved.

Figures

Figure 1.
Figure 1.
Two-way sensitivity analysis of ovarian cancer risk reduction estimates for salpingectomy and bilateral tubal ligation. Blue line signifies the threshold of cost-effectiveness at a willingness-to-pay of $100,000 per QALY. Combinations of input variables below and to the right of the blue line denote circumstances in which salpingectomy is not cost-effective. Green line signifies the threshold of cost-savings. Combinations of input variables above and to the left of the green line denote circumstances in which salpingectomy is cost-saving. Between the blue and green line, salpingectomy is cost-effective.
Figure 2.
Figure 2.
Results of the probabilistic sensitivity analysis. Each blue dot is plotted as the result of a single simulation among 10,000 simulations in probabilistic sensitivity analysis. The black dashed diagonal line is the threshold for cost-effectiveness at a willingness-to-pay of $100,000 per QALY. Dots below and to the right of the diagonal line signify simulations in which salpingectomy was cost-effective. The solid black line forming a circle is the 95% confidence ellipse in which 95% of simulations are expected to result.

References

    1. American Cancer Society. Ovarian cancer. Available at: . Retrieved September 25 2017.
    1. Lowe KA, Chia VM, Taylor A, O’Malley C, et al. An international assessment of ovarian cancer incidence and mortality. Gynecol Oncol 2013;130:107–14.
    1. Kurman RJ, Shih I. The origin and pathogenesis of epithelial ovarian cancer: a proposed unifying theory. Am J Surg Pathol 2010;34:433–43.
    1. Erickson BK, Conner MG, Landen CN Jr. The Role of the fallopian tube in the origin of ovarian cancer. Am J Obstet Gynecol 2013;209:409–14.
    1. Crum CP. Intercepting pelvic cancer in the distal fallopian tube: theories and realities. Mol Oncol 2009;3:165–70.
    1. Kindelberger DW, Lee Y, Miron A, Hirsch MS, et al. Intraepithelial carcinoma of the fimbria and pelvic serous carcinoma: Evidence for a causal relationship. Am J Surg Pathol 2007;31:161–9.
    1. Dilley SE, Straughn JM Jr, Leath CA III. The Evolution of and Evidence for Opportunistic Salpingectomy. Obstet Gynecol 2017;130:814–24.
    1. Walker JL, Powell CB, Chen L, Carter J, et al. Society of Gynecology Oncology recommendations for the prevention of ovarian cancer. Cancer 2015;121:2108–20.
    1. Committee on Gynecologic Practice. Committee opinion no. 620: Salpingectomy for ovarian cancer prevention. Obstet Gynecol 2015;125(1):279–81.
    1. Kwon JS, McAlpine JN, Hanley GE, Finlayson SJ, et al. Costs and benefits of opportunistic salpingectomy as an ovarian cancer prevention strategy. Obstet Gynecol 2015;125:338–45.
    1. Dilley SE, Havrilesky LJ, Bakkum-Gamez J, Cohn D, et al. Cost-effectiveness of opportunistic salpingectomy for ovarian cancer prevention. Gynecol Oncol 2017;146(2):373–379.
    1. Hamilton BE, Martin JA, Osterman MJ. Births: Preliminary Data for 2015. Natl Vital Stat Rep. 2016;65(3): 1–14.
    1. Chan LM, Westhoff Cl. Tubal Sterilization Trends in the United States. Fertil Steril 2010;94:1–6.
    1. Subramaniam A, Blanchard CT, Erickson BK, Szychowski J, et al. Feasibility of Complete salpingectomy compared with standard postpartum tubal ligation at cesarean delivery: a randomized controlled trial. Obstet Gynecol 2018;132(1):20–27.
    1. Kochanek KD, Murphy SL, Xu JQ, Arias E. Mortality in the United States, 2016 NCHS Data Brief, no 293. Hyattsville MD: National Center for Health Statistics; 2017.
    1. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174(4): 1161–8.
    1. Creinin MD, Zite N. Female Tubal Sterilization. Obstet Gynecol 2014;124(3):596–9.
    1. SEER stat fact sheets: ovary cancer. Available at: . Retrieved July 30, 2017.
    1. Falconer H, Yin L, Grönberg H, Altman D. Ovarian cancer risk after salpingectomy: a nationwide population-based study. J Natl Cancer Inst 2015;107(2):dju410.
    1. Madsen C, Baandrup L, Dehlendorff C, Kjaer SK. Tubal ligation and salpingectomy and the risk of epithelial ovarian cancer and borderline ovarian tumors: a nationwide case-control study. Acta Obstet Gynecol Scand 2014;94(1):86–94.
    1. Cibula D, Widschwendter M, Majek O, Dusek L. Tubal ligation and the risk of ovarian cancer: review and meta-analysis. Human Reproduction Update 2010;17(1):55–67.
    1. Rice MS, Murphy MA, Vitonis AF, et al. Tubal ligation, hysterectomy and epithelial ovarian cancer in the New England Case-Control Study. Int J Cancer 2013; 133(10):2415–21.
    1. Rice MS, Hankinson SE, Tworoger SS. Tubal ligation, hysterectomy, unilateral oophorectomy, and risk of ovarian cancer in the Nurses’ Health Studies. Fertility and Sterility 2014; 102(1): 192–3.
    1. Schwarz EB, Smith R, Steinauer J, Reeves MF, Caughey AB. Measuring the effects of unintended pregnancy on women's quality of life. Contraception 2008;78(3):204–10.
    1. Sonnenberg FA, Burkman RT, Hagerty CG, Speroff L, Speroff T. Costs and net health effects of contraceptive methods. Contraception 2004;69(6):447–59.
    1. Gariepy A, Schwarz EB, Lundsberg L. Quantifying the effects of unintended pregnancy on quality of life. Contraception 2016;94(4):433.
    1. Smith KJ, Tsevat J, Ness RB, Wiesenfeld HC, Roberts MS. Quality of Life Utilities for Pelvic Inflammatory Disease Health States. Sexually Transmitted Diseases 2008;35(3):307–11.
    1. Havrilesky LJ, Broadwater G, Davis DM, et al. Determination of quality of life-related utilities for health states relevant to ovarian cancer diagnosis and treatment. Gynecologic Oncology 2009;113(2):216–20.
    1. Sonfield A, Kost K, Gold RB, Finer LB. The public costs of births resulting from unintended pregnancies: national and state-level estimates. Perspect Sex Reprod Health 2011;43(2):94–102.
    1. Amaral G, Foster DG, Biggs MA, Jasik CB, Judd S, Brindis CD. Public Savings from the Prevention of Unintended Pregnancy: A Cost Analysis of Family Planning Services in California. Health Serv Res 2007;42(5): 1960–80.
    1. Lecuru F, Robin F, Chasset S, Leonard F, Guitti S, Taurelle R. Direct cost of single dose methotrexate for unruptured ectopic pregnancy. Prospective comparison with laparoscopy. Eur J Obstet Gynecol Reprod Biol 2000;88(1):1–6.
    1. Mol BW, Hajenius PJ, Engelsbel S, et al. Treatment of tubal pregnancy in the Netherlands: an economic comparison of systemic methotrexate administration and laparoscopic salpingostomy. Am J Obstet Gynecol 1999; 181 (4):945–51.
    1. Sowter MC, Farquhar CM, Gudex G. An economic evaluation of single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured ectopic pregnancy. BJOG 2001;108(2):204–12.
    1. Creinin MD, Washington AE. Cost of ectopic pregnancy management: surgery versus methotrexate. Fertility and Sterility 1993;60(6):963–9.
    1. Bercow AS, Chen L, Chatteijee S, et al. Cost of Care for the Initial Management of Ovarian Cancer. Obstet Gynecol 2017;130(6):1269–75.
    1. Mariotto AB, Robin Yabroff K, Shao Y, Feuer EJ, Brown ML. Projections of the Cost of Cancer Care in the United States: 2010-2020. JNCI: Journal of the National Cancer Institute 2011; 103 (2): 117–28.
    1. Dunn A, Grosse SD, Zuvekas SH. Adjusting Health Expenditures for Inflation: A Review of Measures for Health Services Research in the United States. Health Serv Res 2016;30(3):568.
    1. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness--the curious resilience of the $50,000-per-QALY threshold. N Engl J Med 2014;371(9):796–7.
    1. Shinar S, Blecher Y, Alpern S, Many A, et al. Total bilateral salpingectomy versus partial bilateral salpingectomy for permanent sterilization during cesarean delivery. Arch Gynecol Obstet. 2017. May;295(5): 1185–89.
    1. Ganer Herman H, Gluck O, Keidar R, Kerner R, et al. Ovarian reserve following cesarean section with salpingectomy vs. tubal ligation: a randomized trial. Am J Obstet Gynecol. 2017. October;217(4):472.e1-472.e6.
    1. Powell CB, Alabaster A, Simmons S, Garcia C, et al. Salpingectomy for sterilization: change in practice in a large integrated health care system, 2011-2016. Obstet Gynecol. 2017. November;130(5):961–967.
    1. Ara R, & Brazier JE (2011). Using health state utility values from the general population to approximate baselines in decision analytic models when condition-specific data are not available. Value in Health, 14(4), 539–545.
    1. Szende A, Janssen B, and Cabasés J (2014). Self-reported population health: An international perspective based on EQ-5D (Springer; Netherlands: ).
    1. Danis RB, Della Badia CR, Richard SD. Postpartum permanent sterilization: could bilateral salpingectomy replace bilateral tubal ligation? J Minim Invasive Gynecol. 2016. Sep-Oct;23(6):928–32.
    1. Garcia C, Moskowitz OM, Chisholm CA, Duska LR, et al. Salpingectomy compared with tubal ligation at cesarean delivery: a randomized controlled trial. Obstet Gynecol 132(1):29–34.
    1. Darelius A, Lycke M, Kindblom JM, Kristjansdottir B, et al. Efficacy of salpingectomy at hysterectomy to reduce the risk of epithelial ovarian cancer: a systematic review. BJOG. 2017. May;124(6):880–889.
    1. Macario A What does one minute of operating room time cost? J Clin Anesth. 2010. June;22(4):233–6.
    1. Potz FL, Tomasch G, Polterauer S, Laky R et al. Incidental (Prophylactic) Salpingectomy at Benign Gynecologic Surgery and Cesarean Section: A Survey of Practice in Austria. Geburtshilfe Frauenheilkd. 2016. December;76(12): 1325–1329.

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