Prophylactic Gynecologic Surgery at Time of Colectomy Benefits Women with Lynch Syndrome and Colon Cancer: A Markov Cost-Effectiveness Analysis.

Background Women with Lynch syndrome who have completed childbearing should be offered prophylactic hysterectomy and bilateral salpingo-oophorectomy for gynecologic cancer prevention. The benefit of prophylactic gynecologic surgery at the time of colon cancer resection is unclear. Objective This study aimed to compare the cost, quality of life, and likelihood of being alive and free from colon, endometrial, and ovarian cancer between operative choices for patients with Lynch syndrome undergoing surgery for colon cancer. Design A Markov decision tree spanning 40 years was constructed for a hypothetical cohort of 30-year-old women with Lynch syndrome who had been diagnosed with colon cancer. Outcomes of 6 surgical strategies were compared, including segmental or total abdominal colectomy with or without hysterectomy alone or combined with bilateral salpingo-oophorectomy. Settings A Markov cost-effectiveness analysis was performed at a single center. Patients A literature search was performed identifying studies of patients with genetically diagnosed Lynch syndrome that described cost, risk of mortality, and quality of life after colon cancer resection and prophylactic gynecologic surgery. Main outcome measures The primary outcomes measured were quality-adjusted life-years and the likelihood of being alive and free from colon, endometrial, and ovarian cancer 40 years after surgery. Results Women with Lynch syndrome who underwent a total abdominal colectomy and hysterectomy with bilateral salpingo-oophorectomy had the highest likelihood of being alive and cancer free. Total abdominal colectomy with hysterectomy was a close second, but yielded the largest amount of quality-adjusted life-years and lowest cost. Limitations This study is limited by the statistical method and quality of studies used. Conclusions Total abdominal colectomy with prophylactic hysterectomy at 30 years of age was the most cost-effective surgical choice in women with Lynch syndrome and colon cancer. The addition of bilateral salpingo-oophorectomy offered the highest event-free survival and lowest mortality. However, the additional morbidity of premature menopause of prophylactic salpingo-oophorectomy for younger women outweighed the benefit of ovarian cancer prevention. See Video Abstract at http://links.lww.com/DCR/B287. LA CIRUGIA GINECOLOGICA PROFILACTICA EN EL MOMENTO DE LA COLECTOMIA BENEFICIA A LAS MUJERES CON SINDROME DE LYNCH Y CANCER DE COLON: UN ANALISIS DE COSTO-EFECTIVIDAD DE MARKOV: Las mujeres con sindrome de Lynch que han completado la maternidad deberian recibir histerectomia profilactica y salpingooforectomia bilateral para la prevencion del cancer ginecologico. El beneficio de la cirugia ginecologica profilactica en el momento de la reseccion del cancer de colon no esta claro.Comparar el costo, la calidad de vida y la probabilidad de estar viva y libre de cancer de colon, endometrio y ovario entre las opciones quirurgicas para pacientes con sindrome de Lynch sometidos a cirugia por cancer de colon.Se construyo un arbol de decision de Markov que abarca cuarenta anos para una cohorte hipotetica de mujeres de 30 anos con sindrome de Lynch diagnosticadas con cancer de colon. Se compararon los resultados de seis estrategias quirurgicas, incluida la colectomia abdominal segmentaria o total con o sin histerectomia sola o combinada con salpingooforectomia bilateral.Se realizo un analisis de costo-efectividad de Markov en un solo centro.se realizo una busqueda bibliografica para identificar estudios de pacientes con sindrome de Lynch con diagnostico genetico que describieron el costo, el riesgo de mortalidad y la calidad de vida despues de la reseccion del cancer de colon y la cirugia ginecologica profilactica.anos de vida ajustados por calidad y probabilidad de estar vivo y libre de cancer de colon, endometrio y ovario 40 anos despues de la cirugia.Las mujeres con sindrome de Lynch que se sometieron a una colectomia e histerectomia abdominal total con salpingooforectomia bilateral tuvieron la mayor probabilidad de estar vivas y libres de cancer. La colectomia abdominal total con histerectomia fue un segundo lugar cercano, pero produjo la mayor cantidad de anos de vida ajustados por calidad y el costo mas bajo.Este estudio esta limitado por el metodo estadistico y la calidad de los estudios utilizados.La colectomia abdominal total con histerectomia profilactica a los 30 anos fue la opcion quirurgica mas rentable en mujeres con sindrome de Lynch y cancer de colon. La adicion de salpingooforectomia bilateral ofrecio la mayor supervivencia libre de eventos y la menor mortalidad. Sin embargo, la morbilidad adicional de la menopausia prematura de la salpingooforectomia profilactica para las mujeres mas jovenes supero el beneficio de la prevencion del cancer de ovario. Consulte Video Resumen en http://links.lww.com/DCR/B287. (Traduccion-Dr. Yesenia Rojas-Khalil).