London School of Hygiene & Tropical Medicine

The current threshold for pre-emptive surgery to remove the ovaries and fallopian tubes of women aged 40+ at high risk of developing ovarian cancer should be halved, according to research published online in the Journal of Medical Genetics.

This would not only extend the lives of more women, but would be very cost effective, say the researchers, and help to compensate for the current lack of a reliable test to screen for the disease. The study was co-authored by the London School of Hygiene & Tropical Medicine and UCL (University College London), and led by Queen Mary University London.

Ovarian cancer remains the leading cause of cancers affecting the reproductive system among women. Globally, it kills 152,000 every year. Pre-emptive surgery, known as risk reducing salpingo-oophorectomy, is the best option for curbing ovarian cancer risk among women at high risk of developing the disease. These include women with a first degree relative affected by the disease and carriers of risk genes, such as BRACA1/2, and to a lesser extent, RAD51C, RAD51D, and BRIP1 genes. 

However, the procedure is currently only available to women with at least a 10% lifetime risk of developing the disease, a threshold that has never been tested for its cost effectiveness. The researchers used a mathematical model to compare the costs and effectiveness of pre-emptive surgery, with no surgery for women aged at least 40 who had not yet gone through the menopause, and who were at risk of developing the disease.

Different levels of lifetime risk were included in the analyses-2%, 4%, 5%, 6%, 8% and 10%-to calculate the likelihood of developing ovarian cancer, breast cancer and death from heart disease. Costs were derived from official sources at 2012 prices and average life expectancies for women with and without breast or ovarian cancer were taken from national statistical data to calculate Quality Adjusted Years (QALYs)-a measure of years lived in good health.

When all the data were analysed, the calculations showed that pre-emptive surgery at a lifetime risk level of 4%+ would be highly cost effective among women aged at least 40, and add up to around 43 days in life expectancy if hormone replacement therapy were taken until natural menopause.

Co-author Dr Rosa Legood, from the London School of Hygiene & Tropical Medicine, said: "This is a very important study. Routine clinical testing for risk genes of ovarian cancers is not far away but a reliable test for the disease is seemingly still some way off. It is therefore vital that we understand if the current pre-emptive surgery strategy is cost-effective.

"Our research clearly shows that the current threshold for pre-emptive surgery to remove the ovaries and fallopian tubes of women aged 40+ should be halved. Dropping the level to 4% will allow more women the chance to have surgery which will reduce their risk of developing cancer. It will also help relieve the financial burden on health services by reducing the amount of expensive cancer treatment.

Publication 

• Ranjit Manchanda, Rosa Legood, Antonis C Antoniou, Vladimir S Gordeev, Usha Menon. Specifying the ovarian cancer risk threshold of 'premenopausal risk-reducing salpingo-oophorectomy' for ovarian cancer prevention: a cost effectiveness analysis. Journal of Medical Genetics. DOI:10.1136/jmedgenet-2016-103800=

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