Background
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.
Objective
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.
Study Design
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.
Results
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.
Conclusion
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.
Key words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Obstetrics & GynecologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Perimenopausal management of ovarian endometriosis and associated cancer risk: when is medical or surgical treatment indicated?.Best Pract Res Clin Obstet Gynaecol. 2018; 51: 151-168
National Cancer Institute. SEER Cancer Statistics Review 1975-2013. Available at: https://seer.cancer.gov/statfacts/html/ovary.html. Accessed January 25, 2021. Bethesda, MD: National Cancer Institute; 1975–2013: 2015.
- Risk of gynecologic cancer according to the type of endometriosis.Obstet Gynecol. 2018; 131: 1095-1102
- Association between endometriosis and risk of histological subtypes of ovarian cancer: a pooled analysis of case-control studies.Lancet Oncol. 2012; 13: 385-394
- Risk for and consequences of endometriosis: a critical epidemiologic review.Best Pract Res Clin Obstet Gynaecol. 2018; 51: 1-15
- Management of ovarian endometriomas.Hum Reprod Update. 2002; 8: 591-597
- Assessing research gaps and unmet needs in endometriosis.Am J Obstet Gynecol. 2019; 221: 86-94
- Endometriosis-associated ovarian cancers.Clin Obstet Gynecol. 2017; 60: 711-727
- Surgical prevention strategies in ovarian cancer.Gynecol Oncol. 2018; 151: 166-175
- Ovarian cancer statistics, 2018.CA Cancer J Clin. 2018; 68: 284-296
- Risk of epithelial ovarian cancer in relation to benign ovarian conditions and ovarian surgery.Cancer Causes Control. 2008; 19: 1357-1364
- Endometriosis: seeking optimal management in women approaching menopause.Climacteric. 2019; 22: 329-338
- Hormonal and surgical treatments for endometriosis and risk of epithelial ovarian cancer.Acta Obstet Gynecol Scand. 2013; 92: 546-554
- Long-term mortality associated with oophorectomy compared with ovarian conservation in the nurses’ health study.Obstet Gynecol. 2013; 121: 709-716
- Perioperative outcomes in a nationwide sample of patients undergoing surgical treatment of ovarian endometriomas.Fertil Steril. 2022; 117: 444-453
- Unexpected epithelial ovarian cancers arising from presumed endometrioma: a 10-year retrospective analysis.Taiwan J Obstet Gynecol. 2017; 56: 55-61
- Malignant transformation of ovarian endometriosis.Gynecol Obstet Investig. 2000; 50: 18-25
- Hormone therapy use after premature surgical menopause based on prescription records: a population-based study.J Obstet Gynaecol Can. 2020; 42: 1511-1517
- Tubal ligation, hysterectomy, unilateral oophorectomy, and risk of ovarian cancer in the Nurses’ Health Studies.Fertil Steril. 2014; 102: 192-198.e3
- Ovarian cancer rates after hysterectomy with and without salpingo-oophorectomy.Obstet Gynecol. 2014; 123: 65-72
- Risk of complications in patients with conservatively managed ovarian tumours (IOTA5): a 2-year interim analysis of a multicentre, prospective, cohort study.Lancet Oncol. 2019; 20: 448-458
- Contralateral ovarian endometrioma recurrence after unilateral salpingo-oophorectomy.BMC Womens Health. 2019; 19: 59
- Carcinoma of the ovary.Int J Gynaecol Obstet. 2006; 95: S161-S192
- Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses’ health study.Obstet Gynecol. 2009; 113: 1027-1037
- Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy: a decision analysis.Am J Obstet Gynecol. 2017; 217: 603.e1-603.e6
- Physician fee schedule search. 2021.(Available at:)
- Estrace prices, coupons & savings tips.(Available at:)
- The cost of initial care for medicare patients with advanced ovarian cancer.J Natl Compr Canc Netw. 2016; 14: 429-437
- ACOG Practice Bulletin no. 141: management of menopausal symptoms.Obstet Gynecol. 2014; 123: 202-216
- Departmental guidance on valuation of a statistical life in economic analysis.(Available at:)https://www.transportation.gov/office-policy/transportation-policy/revised-departmental-guidance-on-valuation-of-a-statistical-life-in-economic-analysisDate: 2021Date accessed: August 5, 2021
- Isolated ovarian endometrioma: a history Between myth and reality.J Minim Invasive Gynecol. 2018; 25: 884-891
- The 2017 hormone therapy position statement of the North American Menopause Society.Menopause. 2017; 24: 728-753
- Clinical management of endometriosis.Obstet Gynecol. 2018; 131: 557-571
- Practice Bulletin no. 114: management of endometriosis.Obstet Gynecol. 2010; 116: 223-236
- The management of menopause in women with a history of endometriosis: a systematic review.Hum Reprod Update. 2017; 23: 481-500
- Risk factors of epithelial ovarian carcinomas among women with endometriosis: a systematic review.Acta Obstet Gynecol Scand. 2017; 96: 761-778
- Ovarian cancer risk after salpingectomy: a nationwide population-based study.J Natl Cancer Inst. 2015; 107: 1-6
Article info
Publication history
Published online: April 27, 2022
Accepted:
April 23,
2022
Received in revised form:
April 21,
2022
Received:
December 31,
2021
Footnotes
O.H.C. and R.M.K. are co-senior authors.
The authors report no conflict of interest.
No funding was received for this work.
Cite this article as: Orlando MS, Cadish LA, Shepherd JP, et al. Salpingo-oophorectomy or surveillance for ovarian endometrioma in asymptomatic premenopausal women: a cost-effectiveness analysis. Am J Obstet Gynecol 2022;227:311.e1-7.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
