LAUSR

BACKGROUND Opportunistic salpingectomy at the time of hysterectomy, or as an alternative to bilateral tubal ligation may reduce the incidence of ovarian cancer as it has been demonstrated that most serous ovarian cancers begin in the fallopian tubes. However, salpingectomy at the time of sterilization is not always financially covered by third party payers and this represents a barrier to adoption. Routine salpingectomy has become more common but is not always practiced at the time of hysterectomy. OBJECTIVES To determine the impact of opportunistic salpingectomy as an alternative tubal ligation and routine salpingectomy at the time of hysterectomy on ovarian cancer mortality and overall cost. STUDY DESIGN An eight-state Markov state transition model was constructed including hysterectomy, tubal ligation, and ovarian cancer. Transition probabilities were informed by previously reported population data and include age-adjusted rates of elective sterilization and hysterectomy. This model was used to predict ovarian cancer incidence and the cost effectiveness of opportunistic salpingectomy. Testing of this model suggested that it accurately predicted overall life-expectancy and closely predicted the rate of hysterectomy in the population. The model may underestimate the rate of tubal sterilization making it conservative with respect to the benefits of salpingectomy. RESULTS The recursive Markov model was run from age 20 to 85 in one year intervals with a half step correction and included age adjusted rates of tubal ligation, hysterectomy (with and without oophorectomy), and ovarian cancer. The model predicts opportunistic salpingectomy at the time of tubal ligation will reduce ovarian cancer mortality by 8.13%. Opportunistic salpingectomy at the time of hysterectomy will reduce ovarian cancer mortality by 6.34% for a combined decrease of 14.5%. Both strategies are cost effective when considering only the cost of the opportunistic salpingectomy. The excess cost of opportunistic salpingectomy at the time of tubal ligation was $433.91 with an incremental cost-effective ratio (ICER) of $6,401 per life-yr (LY) and $5,469 per Quality Adjusted Life Year (QALY) gained when adjusting for ovarian cancer with a utility of 0.64. The ICER for opportunistic salpingectomy during hysterectomy at a cost of $124.70 was $2,006 per LY and $1,667 per QALY. When considering the impact of ovarian cancer prevention with respect to the cost of ovarian cancer treatment, opportunistic salpingectomy may produce a substantial healthcare savings. Utilizing a 3% discount rate it is estimated that the total savings for universal salpingectomy could be as high as $445 million annually in the United States. A sensitivity analysis around the benefit of opportunistic salpingectomy suggests that this procedure will be cost effective even if salpingectomy provides only a modest reduction in the risk of ovarian cancer. CONCLUSIONS It is estimated that universal opportunistic salpingectomy may prevent 1,854 deaths per year from ovarian cancer and may reduce heath care costs. Given these data, universal opportunistic salpingectomy should be considered at the time of tubal ligation and hysterectomy and covered by third party payers.