SGO: Preventive Surgery Cost Effective in Lynch Syndrome

SAN DIEGO, March 7 -- Prophylactic surgery is the best bet for women at risk of endometrial and ovarian cancer because of Lynch syndrome, a researcher said here.

In a mathematical model, risk-reducing surgery -- hysterectomy with bilateral salpingo-oophorectomy -- was more cost-effective than annual screening or routine annual check-ups, according to Lee-May Chen, M.D., of the University of California at San Francisco.

Over a lifetime, annual screening was about 2.5 times as expensive as preventive surgery at age 30, and routine check-ups were about 3.5 times as expensive, Dr. Chen said at the Society of Gynecologic Oncologists meeting.

Lynch syndrome -- also known as hereditary non-polyposis colorectal cancer -- also puts women at high risk for endometrial and ovarian cancer. About one person in 2,000 is affected by the syndrome.

Women with the syndrome have a lifetime risk of endometrial cancer that's in the range of 40% to 60%, Dr. Chen said, compared with 2% in the general population. At the same time, their risk of ovarian cancer ranges from 5% to 12%, compared with between 1% and 2% in the general population.

So preventive surgery Dr. Chen said, is a one-shot cost that avoids annual screening costs, future surgery (if the screening discovers abnormalities) and potential cancer care for both screened women and those getting routine care.

The bottom line for preventive surgery, she said, is that "women get less cancer and the health-care system has to pay less for cancer-related costs," she said.

"It's a very good model," commented Bobbie Gostout, M.D., of the Mayo Clinic in Rochester, Minn. "It incorporates everything we know at this time about prevention and the overall prognosis of the disease."

"Given that it's a relatively rare syndrome and given the impact these decisions -- such that a randomized controlled trial will never be possible -- a model may be the best data we're ever going to get," said Dr. Gostout, who was not involved in the research.

Dr. Chen and colleagues used the Surveillance, Epidemiology and End Results (SEER) database from 1988 to 2001 to estimate mortality and data from UCSF to estimate the costs of care.

The cost model included such factors as screening charges, hospital stays, chemotherapy and radiation, surgery, home health care and several other factors, she said.

For example, she said, the cumulative cost of endometrial cancer (in 2006 dollars) would be about ,000 if the patients died five years after diagnosis and about ,000 if she died 10 years after diagnosis.

Even if treatment was successful and the woman was cured, the cost would be about ,000, Dr. Chen said.

In contrast, the researchers estimated the cost of preventive surgery to be about ,000.

The researchers expressed their cost-effectiveness findings using "discounted life-years," which are a statistical method of standardizing patients' perception of the value of an intervention in terms of life expectancy, Dr. Chen said.

For instance, a women getting surgery at age 30 would perceive that the procedure had gained her an additional 25.71 years of life -- even though her actual life might be longer or shorter depending on other factors.

On that basis, Dr. Chen said, preventive surgery has a cost per discounted life-year of , compared with ,406 for annual screening and 3,319 for annual check-ups.

One limitation of the model, Dr. Chen said, is that it doesn't take into account the other risks facing women with Lynch syndrome -- including the risk of colorectal cancer.

But for the physician, it may be a useful tool to help patients understand the risks and benefits of preventive surgery versus other forms of care, she said.

Dr. Gostout pointed out that good screening tools exist for colorectal cancer but many people with Lynch syndrome opt for preventive colectomy to avoid the trauma of developing cancer.

A combination of colectomy, hysterectomy, and bilateral salpingo-oophorectomy would "provide a lot of peace of mind," she said.

"If you've eliminated (the risk of) colon cancer, endometrial cancer, and ovarian cancer, you've eliminated the top three," she said.