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  • 1
    Language: English
    In: Gynecologic Oncology, August 2001, Vol.82(2), pp.367-370
    Description: OBJECTIVE: To conduct a cost-effectiveness analysis of opportunistic salpingectomy (elective salpingectomy at hysterectomy or instead of tubal ligation).METHODS: A Markov Monte Carlo simulation model estimated the costs and benefits of opportunistic salpingectomy in a hypothetical cohort of women undergoing hysterectomy for benign gynecologic conditions or surgical sterilization. The primary outcome measure was the incremental cost-effectiveness ratio. Effectiveness was measured in terms of life expectancy gain. Sensitivity analyses accounted for uncertainty around various parameters. Monte Carlo simulation estimated the number of ovarian cancer cases associated with each strategy in the Canadian population.RESULTS: Salpingectomy with hysterectomy was less costly ($11,044.32 ± $1.56) than hysterectomy alone ($11,206.52 ± $29.81) or with bilateral salpingo-oophorectomy ($12,626.84 ± $13.11) but more effective at 21.12 ± 0.02 years compared with 21.10 ± 0.03 and 20.94 ± 0.03 years, representing average gains of 1 week and 2 months, respectively. For surgical sterilization, salpingectomy was more costly ($9,719.52 ± $3.74) than tubal ligation ($9,339.48 ± $26.74) but more effective at 22.45 ± 0.02 years compared with 22.43 ± 0.02 years (average gain of 1 week) with an incremental cost-effectiveness ratio of $27,278 per year of life gained. Our results were stable over a wide range of costs and risk estimates. Monte Carlo simulation predicted that salpingectomy would reduce ovarian cancer risk by 38.1% (95% confidence interval [CI] 36.5-41.3%) and 29.2% (95% CI 28.0-31.4%) compared with hysterectomy alone or tubal ligation, respectively.CONCLUSION: Salpingectomy with hysterectomy for benign conditions will reduce ovarian cancer risk at acceptable cost and is a cost-effective alternative to tubal ligation for sterilization. Opportunistic salpingectomy should be considered for all women undergoing these surgical procedures.
    Keywords: Gestational Trophoblastic Neoplasia ; Weekly Intravenous Methotrexate ; Complete Response ; Β-Hcg Titer ; Medicine
    ISSN: 0090-8258
    ISSN: 1873233X
    E-ISSN: 1095-6859
    E-ISSN: 1873233X
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  • 2
    Language: English
    In: The Journal of Urology, January 2013, Vol.189(1), pp.17-24
    Description: Penile carcinoma is rare in the developed world and treatment guidelines are often based on marginal clinical data. Prospective controlled studies are virtually absent and meta-analyses are rare. Vulvar carcinoma, on the other hand, has many parallels to penile carcinoma, and the level of evidence for diagnosis and treatment is more robust. Therefore, we assessed the body of literature on vulvar carcinoma to identify potential improvements in the care of patients with penile carcinoma. A literature review was performed on vulvar carcinoma and direct comparisons were made to a similar review of the literature on penile carcinoma. Several aspects of vulvar carcinoma management are clearly established and deserve closer evaluation in penile carcinoma. For example, human papillomavirus is identified in a high percentage of patients with vulvar carcinoma but is understudied in penile carcinoma. Further study is of potential clinical value, especially with the development of human papillomavirus vaccines for prevention. Penile carcinoma TNM staging does not adequately stratify survival or risk of advanced disease. Staging of vulvar carcinoma is dependent on tumor size and depth of invasion measured in millimeters, as opposed to the invasion of underlying structures in penile carcinoma. Management of the inguinal nodes is more refined for vulvar carcinoma, where lymphatic mapping has been conducted and sentinel node biopsy has proven to be highly effective in multicenter trials. Finally, the efficacy of adjuvant radiation and chemotherapy has been tested in controlled trials or reported in meta-analyses for vulvar carcinoma, which are both lacking for penile carcinoma. Radiation after inguinal node dissection, for example, has been shown to enhance survival in patients with defined risk factors. Neoadjuvant chemoradiation is recommended before surgery for advanced vulvar carcinoma. Evidence derived from studies on vulvar carcinoma can be extrapolated to penile carcinoma to help guide clinical trials and future research directions to enhance the treatment of these patients.
    Keywords: Penile Neoplasms ; Vulvar Neoplasms ; Carcinoma, Squamous Cell ; Neoplasm Staging ; Disease Management ; Medicine
    ISSN: 0022-5347
    E-ISSN: 1527-3792
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  • 3
    In: Obstetrics & Gynecology, 2017, Vol.129 Suppl 1, pp.4S-4S
    Description: INTRODUCTION:: Breast cancer is the most common cancer among women in America, and gynecologists often encounter these women in their practice. After 5 years of adjuvant tamoxifen, women with ER+ breast cancer benefit from extended endocrine therapy, either with tamoxifen or an aromatase inhibitor (AI). For premenopausal women, ovarian ablation (OA) is required before starting an AI, but there is concern about the long-term outcomes (osteoporosis, heart disease) and costs of OA. METHODS:: A Markov Monte Carlo simulation model estimated the costs and benefits of extended endocrine strategies in a hypothetical cohort of premenopausal women with ER+ cancer: (1) no further treatment; (2) tamoxifen for 5 years; (3) OA followed by AI for 5 years (OA/AI). Effectiveness was measured in years of life expectancy gain. Monte Carlo simulation estimated the number of adverse events and deaths from each strategy in the American population over a 40-year horizon. RESULTS:: Tamoxifen for 5 more years yielded a higher average discounted life expectancy gain than OA/AI (16.57 vs. 16.34 years) at lower average cost ($2,976 vs. $10,150). For 18,000 ER+ premenopausal women diagnosed annually, the simulation estimated 12,526, 11,508, and 10,289 deaths after no further treatment, tamoxifen and OA/AI respectively, but another 2,139 deaths from long-term consequences of OA. According to sensitivity analyses, women had to be over 50.8 years of age before OA/AI became cost-effective. CONCLUSION:: As extended endocrine therapy for premenopausal ER+ breast cancer, another 5 years of tamoxifen is more effective and less costly than ovarian ablation followed by 5 years of aromatase inhibitor.
    ISSN: 0029-7844
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  • 4
    In: Obstetrics & Gynecology, 2018, Vol.131 Suppl 1, pp.2S-2S
    Description: INTRODUCTION:: Women with high-grade serous ovarian cancer (HGSC) have a 20% chance of carrying a BRCA1 or BRCA2 mutation and are eligible for BRCA testing. Many are untested, therefore their female first-degree relatives (FDR) may not qualify for testing unless they have specific ethnicity or other personal/family cancer history. We conducted a cost-effectiveness analysis to evaluate BRCA mutation testing for these FDR who are otherwise ineligible for testing. METHODS:: A Markov Monte Carlo simulation model estimated the costs and benefits of 3 strategies for female FDR of HGSC patients whose BRCA status is unknown: 1) no BRCA testing; 2) universal BRCA testing, followed by risk-reducing bilateral salpingo-oophorectomy (RRBSO) for mutation carriers (“BRCA testing”); 3) universal RRBSO, without BRCA testing (“RRBSO”). Effectiveness was estimated in quality-adjusted life year (QALY) gains. Sensitivity analyses accounted for uncertainty around various parameters. The time horizon was 50 years. RESULTS:: BRCA testing for female FDR of HGSC patients yielded a higher average QALY gain at acceptable cost compared to no BRCA testing, with an ICER of $7,729 per QALY. BRCA testing was more effective and less costly than RRBSO (19.20 QALYs vs 18.48 QALYs, and $10,108.35 vs $13,959.20, respectively), therefore BRCA testing is the dominant strategy. Results were stable over a wide range of plausible costs and estimates. Compliance with hormone replacement therapy had to exceed 84% for RRBSO to be the preferred strategy. CONCLUSION:: BRCA mutation testing should be offered to all female first-degree relatives of women with high-grade serous ovarian cancer when their BRCA mutation status is unknown.
    ISSN: 0029-7844
    Source: Copyright © 2013 Lippincott Williams & Wilkins. All rights reserved.〈img src=http://exlibris-pub.s3.amazonaws.com/LWW%20logo.png style="vertical-align:middle;margin-left:7px"〉
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  • 5
    Language: English
    In: Journal of gynecologic oncology, April 2015, Vol.26(2), pp.83-6
    Description: There has been increasing evidence over the past decade that the majority of ovarian cancers arise in the fallopian tube and not primarily in the ovary [1,2,3]. In 2010 the British Columbia Ovarian Cancer Research Group (OVCARE) launched an educational campaign about the potential benefit of "opportunistic salpingectomy" done concurrently with hysterectomy for benign gynecologic conditions, or instead of tubal ligation as surgical sterilization. It was estimated that this practice could reduce ovarian cancer risk by 20% to 40% over the next 20 years [4]. Salpingectomy is favorable to salpingo-oophorectomy because it avoids health risks associated with premature menopause after oophorectomy, including osteoporosis and coronary heart disease [5]. However, there has been skepticism about the safety and absolute benefit of this practice [6,7]. There are no long-term studies confirming that salpingectomy does not compromise ovarian function. Similarly, there are no long-term clinical studies confirming that the fallopian tube is the site of origin of most ovarian cancers. However, the available evidence so far suggests that opportunistic salpingectomy is safe, and likely to be effective and cost-effective as an ovarian cancer prevention strategy.
    Keywords: Elective Surgical Procedures ; Risk Reduction Behavior ; Ovarian Neoplasms -- Prevention & Control ; Salpingectomy -- Statistics & Numerical Data
    ISSN: 20050380
    E-ISSN: 2005-0399
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  • 6
    In: Clinical Obstetrics and Gynecology, 2017, Vol.60(4), pp.780-788
    Description: Ovarian cancer remains to be the most lethal of all gynecologic malignancies. There is no effective screening test proven to reduce the mortality associated with this disease. Costs of treating ovarian cancer are substantial and among the highest of all cancer types. Therefore, it is essential to pursue strategies to prevent ovarian cancer that are cost-effective in the context of our health care system. There are 2 subgroups of women for whom ovarian cancer prevention strategies have been evaluated for effectiveness and costs: (1) general population at risk, and (2) BRCA mutation carriers with a high lifetime risk.
    Keywords: Cost-Benefit Analysis ; Early Detection of Cancer -- Economics ; Genetic Testing -- Economics ; Ovarian Neoplasms -- Economics ; Prophylactic Surgical Procedures -- Economics;
    ISSN: 0009-9201
    E-ISSN: 15325520
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  • 7
    Language: English
    In: Journal of gynecologic oncology, July 2015, Vol.26(3), pp.227-31
    Description: To improve survival in women with endometrial cancer, we need to look at the "big picture" beyond initial treatment. Although the majority of women will be diagnosed with early stage disease and are cured with surgery alone, there is a subgroup of women with advanced and high-risk early stage disease whose life expectancy may be prolonged with the addition of chemotherapy. Immunohistochemistry will help to identify those women with Lynch syndrome who will benefit from more frequent colorectal cancer surveillance and genetic counseling. If they happen to be diagnosed with colorectal cancer, this information has an important therapeutic implication. And finally, because the majority of women will survive their diagnosis of endometrial cancer, they remain at risk for breast and colorectal cancer, so these women should be counselled about screening for these cancers. These three interventions will contribute to improving the overall survival of women with endometrial cancer.
    Keywords: Colorectal Neoplasms, Hereditary Nonpolyposis ; Endometrial Neoplasms ; Endometrial Neoplasms -- Mortality
    ISSN: 20050380
    E-ISSN: 2005-0399
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  • 8
    Language: English
    In: American Journal of Obstetrics and Gynecology, August 2018, Vol.219(2), pp.172.e1-172.e8
    Description: Recent evidence has suggested that the fallopian tube may often be the site of origin for the most common and lethal form of ovarian cancer. As a result, many Colleges of Obstetrics and Gynecology, including the American College of Obstetricians and Gynecology, are recommending surgical removal of the fallopian tube (bilateral salpingectomy) at the time of other gynecologic surgeries (particularly hysterectomy and tubal sterilization) in women at general population risk for ovarian cancer, collectively referred to as opportunistic salpingectomy. Previous research with the use of hospital data has indicated good perioperative safety of opportunistic salpingectomy, but no data on minor complications have been presented. Herein, we examine whether women who undergo opportunistic salpingectomy are at increased risk of minor complications after surgery. We identified all women in British Columbia who underwent opportunistic salpingectomy between 2008 and 2014 and examined all physician visits in the 2 weeks after discharge from the hospital. We compared women who underwent opportunistic salpingectomy at hysterectomy with women who underwent hysterectomy alone and women who underwent opportunistic salpingectomy for sterilization with women who underwent tubal ligation. We examined visits for surgical infection, surgical complication, orders for laboratory tests, and orders for imaging (x-ray, ultrasound scan, or computed tomography scan) and whether women who underwent opportunistic salpingectomy were more likely to fill a prescription for an antibiotic or analgesic in the 2 weeks after discharge from the hospital. We calculated adjusted odds ratios for these outcomes, adjusting for other gynecologic conditions, surgical approach, and patient age. We included 49,275 women who had undergone a hysterectomy alone, a hysterectomy with opportunistic salpingectomy, a hysterectomy with bilateral salpingo-oophorectomy, a tubal ligation, or an opportunistic salpingectomy for sterilization. In women who had undergone opportunistic salpingectomy, there was no increased risk for physician visits for surgical infection, surgical complication, ordering a laboratory test, or ordering imaging in the 2 weeks after discharge. There was no increased risk of filling a prescription for an antibiotic. However, women who underwent opportunistic salpingectomy were at approximately 20% increased odds of filling a prescription for an analgesic in the 2 weeks after discharge from the hospital (adjusted odds ratio, 1.23; 95% confidence interval, 1.15–1.32 for hysterectomy with opportunistic salpingectomy; adjusted odds ratio, 1.21; 95% confidence interval, 1.14–1.29 for opportunistic salpingectomy for sterilization). We report no differences in minor complications between women who undergo opportunistic salpingectomy and women who undergo hysterectomy alone or tubal ligation, except for a slightly increased likelihood of filling a prescription for analgesic medication in the immediate 2 weeks after discharge.
    Keywords: Bilateral Salpingectomy ; Hysterectomy ; Ovarian Cancer Prevention ; Sterilization ; Medicine
    ISSN: 0002-9378
    E-ISSN: 1097-6868
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  • 9
    In: Obstetrics & Gynecology, 2013, Vol.121(1), pp.14-24
    Description: OBJECTIVE:: Prophylactic bilateral salpingo-oophorectomy is advised for women with BRCA mutations, but there are adverse consequences of premature menopause. The majority of BRCA-associated ovarian cancers appear to arise in the fallopian tube; therefore, salpingectomy may be an alternative to bilateral salpingo-oophorectomy. We compared the costs and benefits of salpingectomy with bilateral salpingo-oophorectomy among BRCA mutation carriers. METHODS:: We developed a Markov Monte Carlo simulation model to compare three strategies for risk reduction in women with BRCA mutations: 1) bilateral salpingo-oophorectomy; 2) bilateral salpingectomy; and 3) bilateral salpingectomy with delayed oophorectomy. Net health benefits were measured in years-of-life expectancy and quality-adjusted life-year expectancy, and the primary outcome was the incremental cost-effectiveness ratio. The model estimated the number of future breast and ovarian cancers and cardiovascular deaths attributed to premature menopause with each strategy. RESULTS:: Bilateral salpingo-oophorectomy was associated with the lowest cost and highest life expectancy compared with the other two strategies. When quality-of-life measures were included, salpingectomy followed by delayed oophorectomy yielded the highest quality-adjusted life expectancy with incremental cost-effectiveness ratios of $37,805 and $89,680 per quality-adjusted life-year for BRCA1 and BRCA2, respectively, relative to salpingectomy alone. Bilateral salpingo-oophorectomy yielded the lowest number of future breast and ovarian cancers compared with the other two strategies. CONCLUSION:: Bilateral salpingo-oophorectomy offers the greatest risk reduction for breast and ovarian cancer among BRCA mutation carriers. However, when considering quality-adjusted life expectancy, bilateral salpingectomy with delayed oophorectomy is a cost-effective strategy and may be an acceptable alternative for those unwilling to undergo bilateral salpingo-oophorectomy.
    Keywords: Genes, Brca1 ; Genes, Brca2 ; Breast Neoplasms -- Prevention & Control ; Ovarian Neoplasms -- Prevention & Control ; Ovariectomy -- Methods ; Salpingectomy -- Methods;
    ISSN: 0029-7844
    E-ISSN: 1873233X
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  • 10
    Language: English
    In: International Journal of Radiation Oncology, Biology, Physics, 15 July 2012, Vol.83(4), pp.1179-1184
    Description: Concurrent cisplatin-based chemoradiotherapy (CRT) is the standard treatment for locally advanced cervical cancer. RTOG 0417 was a Phase II study exploring the safety and efficacy of the addition of bevacizumab to standard CRT. Eligible patients with bulky tumors (Stage IB-IIIB) were treated with once-weekly cisplatin (40 mg/m ) chemotherapy and standard pelvic radiotherapy and brachytherapy. Bevacizumab was administered at 10 mg/kg intravenously every 2 weeks for three cycles. Treatment-related serious adverse event (SAE) and other adverse event (AE) rates within the first 90 days from treatment start were determined. Treatment-related SAEs were defined as any Grade ≥4 vaginal bleeding or thrombotic event or Grade ≥3 arterial event, gastrointestinal (GI) bleeding, or bowel/bladder perforation, or any Grade 5 treatment-related death. Treatment-related AEs included all SAEs and Grade 3 or 4 GI toxicity persisting for 〉2 weeks despite medical intervention, Grade 4 neutropenia or leukopenia persisting for 〉7 days, febrile neutropenia, Grade 3 or 4 other hematologic toxicity, and Grade 3 or 4 GI, renal, cardiac, pulmonary, hepatic, or neurologic AEs. All AEs were scored using the National Cancer Institute Common Terminology Criteria (CTCAE) v 3.0 (MedDRA version 6.0). A total of 60 patients from 28 institutions were enrolled between 2006 and 2009, and of these, 49 patients were evaluable. The median follow-up was 12.4 months (range, 4.6–31.4 months).The median age was 45 years (range, 22–80 years). Most patients had FIGO Stage IIB (63%) and were of Zubrod performance status of 0 (67%). 80% of cases were squamous. There were no treatment-related SAEs. There were 15 (31%) protocol-specified treatment–related AEs within 90 days of treatment start; the most common were hematologic (12/15; 80%). 18 (37%) occurred during treatment or follow-up at any time. 37 of the 49 patients (76%) had cisplatin and bevacizumab administered per protocol, and 46 of the 49 (94%) had both external beam and brachytherapy administered per protocol or with acceptable variation. Bevacizumab in addition to standard pelvic chemoradiotherapy for locally advanced cervical cancer is feasible and safe with respect to the protocol-specified treatment–related SAEs and AEs.
    Keywords: Chemoradiation ; Bevacizumab ; Rtog Phase II Trial Results ; Cervical Cancer ; Medicine
    ISSN: 0360-3016
    E-ISSN: 1879-355X
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