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BACKGROUND: Parallel panel germline and somatic genetic testing of all patients with ovarian cancer (OC) can identify more pathogenic variants (PVs) that would benefit from PARP inhibitor (PARPi) therapy, and allow for precision prevention in unaffected relatives with PVs. In this study, we estimate the cost-effectiveness and population impact of parallel panel germline and somatic BRCA testing of all patients with OC incorporating PARPi therapy in the United Kingdom and the United States compared with clinical criteria/family history (FH)-based germline BRCA testing. We also evaluate the cost-effectiveness of multigene panel germline testing alone. METHODS: Microsimulation cost-effectiveness modeling using data from 2,391 (UK: n=1,483; US: n=908) unselected, population-based patients with OC was used to compare lifetime costs and effects of panel germline and somatic BRCA testing of all OC cases (with PARPi therapy) (strategy A) versus clinical criteria/FH-based germline BRCA testing (strategy B). Unaffected relatives with germline BRCA1/BRCA2/RAD51C/RAD51D/BRIP1 PVs identified through cascade testing underwent appropriate OC and breast cancer (BC) risk-reduction interventions. We also compared the cost-effectiveness of multigene panel germline testing alone (without PARPi therapy) versus strategy B. Unaffected relatives with PVs could undergo risk-reducing interventions. Lifetime horizon with payer/societal perspectives, along with probabilistic/one-way sensitivity analyses, are presented. Incremental cost-effectiveness ratio (ICER) and incremental cost per quality-adjusted life year (QALY) gained were compared with £30,000/QALY (UK) and $100,000/QALY (US) thresholds. OC incidence, BC incidence, and prevented deaths were estimated. RESULTS: Compared with clinical criteria/FH-based BRCA testing, BRCA1/BRCA2/RAD51C/RAD51D/BRIP1 germline testing and BRCA1/BRCA2 somatic testing of all patients with OC incorporating PARPi therapy had a UK ICER of £51,175/QALY (payer perspective) and £50,202/QALY (societal perspective) and a US ICER of $175,232/QALY (payer perspective) and $174,667/QALY (societal perspective), above UK/NICE and US cost-effectiveness thresholds in the base case. However, strategy A becomes cost-effective if PARPi costs decrease by 45% to 46% or if overall survival with PARPi reaches a hazard ratio of 0.28. Unselected panel germline testing alone (without PARPi therapy) is cost-effective, with payer-perspective ICERs of £11,291/QALY or $68,808/QALY and societal-perspective ICERs of £6,923/QALY or $65,786/QALY. One year's testing could prevent 209 UK BC/OC cases and 192 deaths, and 560 US BC/OC cases and 460 deaths. CONCLUSIONS: Unselected panel germline and somatic BRCA testing can become cost-effective, with a 45% to 46% reduction in PARPi costs. Regarding germline testing, unselected panel germline testing is highly cost-effective and should replace BRCA testing alone.
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Carcinoma Epitelial do Ovário , Análise Custo-Benefício , Testes Genéticos , Mutação em Linhagem Germinativa , Neoplasias Ovarianas , Humanos , Feminino , Testes Genéticos/economia , Testes Genéticos/métodos , Carcinoma Epitelial do Ovário/genética , Carcinoma Epitelial do Ovário/economia , Carcinoma Epitelial do Ovário/diagnóstico , Carcinoma Epitelial do Ovário/tratamento farmacológico , Carcinoma Epitelial do Ovário/patologia , Neoplasias Ovarianas/genética , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/economia , Predisposição Genética para Doença , Proteína BRCA2/genética , Proteína BRCA1/genética , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Anos de Vida Ajustados por Qualidade de Vida , Inibidores de Poli(ADP-Ribose) Polimerases/uso terapêutico , Inibidores de Poli(ADP-Ribose) Polimerases/economia , RNA Helicases/genética , Adulto , Reino Unido/epidemiologia , Proteínas de Grupos de Complementação da Anemia de Fanconi/genética , Proteínas de Ligação a DNARESUMO
PURPOSE OF REVIEW: To describe current and future strategies to reduce the burden of ovarian cancer through prevention. RECENT FINDINGS: Current strategies in genetic testing are missing a substantial number of individuals at risk, representing a missed opportunity for ovarian cancer prevention. Past efforts at screening and early detection have thus far failed to improve ovarian cancer mortality, and novel techniques are needed. Surgical prevention is highly effective, but surgical menopause from oophorectomy has significant side effects. Novel surgical strategies aimed at reducing risk while minimizing these harms are currently being studied. To maximize ovarian cancer prevention, a multi-pronged approach is needed. We propose that more inclusive and accurate genetic testing to identify more individuals at risk, novel molecular screening and early detection, surgical prevention that maximizes quality of life while reducing risk, and broader adoption of targeted and opportunistic salpingectomy will together reduce the burden of ovarian cancer.
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OBJECTIVES: Previously we have shown in endometrial cells that progesterone (P4) and calcitriol (CAL, 1,25(OH)2D3) synergistically promote apoptosis and that progestins induce expression of the vitamin D receptor. In the current study we examined the progestin/vitamin D combination in ovarian cells and searched for other progestin-related effects on vitamin D metabolism that may underlie the novel interaction between progestins and vitamin D, including whether progestins inhibit CYP24A1, the enzyme that renders CAL inactive. METHODS: We investigated the impact of P4 on CAL-induced CYP24A1 expression in cancer cell lines expressing progesterone receptors (PRs), [OVCAR-5, OVCAR-3-PGR (PR-transfected OVCAR-3 ovarian line), and T47D-WT, T47D-A and T47D-B (breast lines expressing PRs or individual PR isoforms)] or lines that do not express PRs (OVCAR-3 and T47D-Y). We examined CYP24A1 expression using RT-PCR and western blotting, and apoptosis by TUNEL. We also investigated P4 inhibition of Cyp24a1 in ovaries from CAL-treated mice. RESULTS: CAL treatment induced CYP24A1 expression. When co-treated with P4, cell lines expressing PRs showed marked inhibition of CYP24A1 expression (p<0.001), along with increased apoptosis (p<0.01); cells not expressing PRs did not. Mouse ovaries showed a significant reduction in CAL-induced Cyp24a1 mRNA (p<0.001) and protein (p<0.01) in response to P4. CONCLUSIONS: We show for the first time that progestins and vitamin D synergistically reduce cell viability and induce apoptosis in ovarian cells and that progestins PR-dependently inhibit CAL-induced CYP24A1, thus extending CAL activity. The combination of progestins and vitamin D deserves further consideration as a strategy for inhibiting ovarian carcinogenesis.
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Calcitriol/farmacologia , Quimioprevenção , Neoplasias Ovarianas/tratamento farmacológico , Progesterona/farmacologia , Vitamina D3 24-Hidroxilase/antagonistas & inibidores , Animais , Linhagem Celular Tumoral , Sobrevivência Celular/efeitos dos fármacos , Sinergismo Farmacológico , Feminino , Humanos , Camundongos , Camundongos Endogâmicos C57BL , Neoplasias Ovarianas/patologia , Ovário/enzimologia , Receptores de Progesterona/análise , Receptores de Progesterona/fisiologiaRESUMO
PURPOSE: To assess implementation of a next-generation sequencing (NGS) assay to detect microsatellite instability (MSI) as a screen for Lynch syndrome (LS) in endometrial cancer (EC), while determining and comparing characteristics of the four molecular subtypes. METHODS: A retrospective review was performed of 408 total patients with newly diagnosed EC: 140 patients who underwent universal screening with NGS and 268 patients who underwent screening via mismatch repair immunohistochemistry (MMR IHC) as part of a historical screening paradigm. In the NGS cohort, incidental POLE and TP53 mutations along with MSI were identified and used to characterize EC into molecular subtypes: POLE-ultramutated, MSI high (MSI-H), TP53-mutated, and no specific molecular profile (NSMP). In historical cohorts, age- and/or family history-directed screening was performed with MMR IHC. Statistical analysis was performed using a t-test for continuous variables and chi-square or Fisher's exact test for categorical variables. RESULTS: In the NGS cohort, 38 subjects (27%) had MSI-H EC, 100 (71%) had microsatellite stable EC, and two (1%) had an indeterminate result. LS was diagnosed in two subjects (1%), and all but five patients completed genetic screening (96%). Molecular subtypes were ascertained: eight had POLE-ultramutated EC, 28 had TP53-mutated EC (20%), and 66 (47%) had NSMP. MSI-H and TP53-mutated EC had worse prognostic features compared with NSMP EC. Comparison with historical cohorts demonstrated a significant increase in follow-up testing after an initial positive genetic screen in the MSI NGS cohort (56% v 89%; P = .001). CONCLUSION: MSI by NGS allowed for simultaneous screening for LS and categorization of EC into molecular subtypes with prognostic and therapeutic implications.
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Neoplasias Colorretais Hereditárias sem Polipose , Neoplasias do Endométrio , Feminino , Humanos , Instabilidade de Microssatélites , Testes Genéticos , Neoplasias do Endométrio/diagnóstico , Neoplasias do Endométrio/genética , Mutação , Neoplasias Colorretais Hereditárias sem Polipose/genética , Sequenciamento de Nucleotídeos em Larga EscalaRESUMO
Importance: Overprescription of opioid medications following surgery is well documented. Current prescribing models have been proposed in narrow patient populations, which limits their generalizability. Objective: To develop and validate a model for predicting outpatient opioid use following a range of gynecological surgical procedures. Design, Setting, and Participants: In this prognostic study, statistical models were explored using data from a training cohort of participants undergoing gynecological surgery for benign and malignant indications enrolled prospectively at a single institution's academic gynecologic oncology practice from February 2018 to March 2019 (cohort 1) and considering 39 candidate predictors of opioid use. Final models were internally validated using a separate testing cohort enrolled from May 2019 to February 2020 (cohort 2). The best final model was updated by combining cohorts, and an online calculator was created. Data analysis was performed from March to May 2020. Exposures: Participants completed a preoperative survey and weekly postoperative assessments (up to 6 weeks) following gynecological surgery. Pain management was at the discretion of clinical practitioners. Main Outcomes and Measures: The response variable used in model development was number of pills used postoperatively, and the primary outcome was model performance using ordinal concordance and Brier score. Results: Data from 382 female adult participants (mean age, 56 years; range, 18-87 years) undergoing gynecological surgery (minimally invasive procedures, 158 patients [73%] in cohort 1 and 118 patients [71%] in cohort 2; open surgical procedures, 58 patients [27%] in cohort 1 and 48 patients [29%] in cohort 2) were included in model development. One hundred forty-seven patients (38%) used 0 pills after hospital discharge, and the mean (SD) number of pills used was 7 (10) (median [IQR], 3 [0-10] pills). The model used 7 predictors: age, educational attainment, smoking history, anticipated pain medication use, anxiety regarding surgery, operative time, and preoperative pregabalin administration. The ordinal concordance was 0.65 (95% CI, 0.62-0.68) for predicting 5 or more pills (Brier score, 0.22), 0.65 (95% CI, 0.62-0.68) for predicting 10 or more pills (Brier score, 0.18), and 0.65 (95% CI, 0.62-0.68) for predicting 15 or more pills (Brier score, 0.14). Conclusions and Relevance: This model provides individualized estimates of outpatient opioid use following a range of gynecological surgical procedures for benign and malignant indications with all model inputs available at the time of procedure closing. Implementation of this model into the clinical setting is currently ongoing, with plans for additional validation in other surgical populations.
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Analgésicos Opioides , Prescrições de Medicamentos , Procedimentos Cirúrgicos em Ginecologia , Dor Pós-Operatória , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/administração & dosagem , Feminino , Humanos , Pessoa de Meia-Idade , Modelos Estatísticos , Manejo da Dor , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica , Adulto JovemRESUMO
Triple-negative breast cancer (TNBC) and ovarian carcinomas (OvCas) with BRCA1 promoter methylation (BRCA1meth) respond more poorly to alkylating agents compared to those bearing mutations in BRCA1 and BRCA2 (BRCAmut). This is a conundrum given the biologically equivalent homologous recombination deficiency (HRD) induced by these genetic and epigenetic BRCA perturbations. We dissected this problem through detailed genomic analyses of TNBC and OvCa cohorts and experimentation with patient-derived xenografts and genetically engineered cell lines. We found that despite identical downstream genomic mutational signatures associated with BRCA1meth and BRCAmut states, BRCA1meth uniformly associates with poor outcomes. Exposure of BRCA1meth TNBCs to platinum chemotherapy, either as clinical treatment of a patient or as experimental in vivo exposure of preclinical patient derived xenografts, resulted in allelic loss of BRCA1 methylation and increased BRCA1 expression and platinum resistance. These data suggest that, unlike BRCAmut cancers, where BRCA loss is a genetically "fixed" deficiency state, BRCA1meth cancers are highly adaptive to genotoxin exposure and, through reversal of promoter methylation, recover BRCA1 expression and become resistant to therapy. We further found a specific augmented immune transcriptional signal associated with enhanced response to platinum chemotherapy but only in patients with BRCA-proficient cancers. We showed how integrating both this cancer immune signature and the presence of BRCA mutations results in more accurate predictions of patient response when compared to either HRD status or BRCA status alone. This underscores the importance of defining BRCA heterogeneity in optimizing the predictive precision of assigning response probabilities in TNBC and OvCa.
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Carcinoma , Neoplasias Ovarianas , Neoplasias de Mama Triplo Negativas , Proteína BRCA1/genética , Proteína BRCA1/metabolismo , Proteína BRCA2/genética , Proteína BRCA2/metabolismo , Epigenômica , Feminino , Genômica , Humanos , Mutação/genética , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/genética , Platina/farmacologia , Platina/uso terapêutico , Neoplasias de Mama Triplo Negativas/tratamento farmacológico , Neoplasias de Mama Triplo Negativas/genética , Neoplasias de Mama Triplo Negativas/metabolismoRESUMO
Here, we evaluated the expression of CYP24A1, a protein that inactivates vitamin D in tissues. CYP24A1 expression was increased in advanced-stage endometrial tumors compared to normal tissues. Similarly, endometrial cancer cells expressed higher levels of CYP24A1 than immortalized endometrial epithelial cells. RT-PCR and Western blotting were used to examine CYP24A1 mRNA and protein levels in endometrial cancer cells after 8, 24, 72, and 120 h of exposure to progesterone, progestin derivatives and calcitriol, either alone or in combination. Progestins inhibited calcitriol-induced expression of CYP24A1 and splice variant CYP24SV mRNA and protein in cancer cells. Furthermore, actinomycin D, but not cycloheximide, blocked calcitriol-induced CYP24A1 splicing. siRNA-induced knockdown of CYP24A1 expression sensitized endometrial cancer cells to calcitriol-induced growth inhibition. These data suggest that CYP24A1 overexpression reduces the antitumor effects of calcitriol in cancer cells and that progestins may be beneficial for maintaining calcitriol's anti-endometrial cancer activity.
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Calcitriol/farmacologia , Neoplasias do Endométrio/patologia , Progesterona/farmacologia , Vitamina D3 24-Hidroxilase/genética , Vitamina D3 24-Hidroxilase/metabolismo , Adulto , Idoso , Linhagem Celular Tumoral , Proliferação de Células/efeitos dos fármacos , Sinergismo Farmacológico , Neoplasias do Endométrio/genética , Neoplasias do Endométrio/metabolismo , Feminino , Regulação Neoplásica da Expressão Gênica/efeitos dos fármacos , Humanos , Pessoa de Meia-Idade , Gradação de TumoresRESUMO
BACKGROUND: The effect of different sociodemographic and clinical variables on the health-related quality of life (HRQOL) of patients with inflammatory bowel disease (IBD) is currently known, but the influence of psychological factors has not been sufficiently explored. The objective of this study was to identify psychological predictors of HRQOL in patients with IBD. METHODS: A cross-sectional prospective study was undertaken including 875 consecutive IBD patients. Independent variables were measured using a sociodemographic and clinical questionnaire, the Hospital Anxiety and Depression Scale (HADS) questionnaire, the Perceived Stress Scale (PSS) questionnaire, and the COPE questionnaire. Dependent variables were measured using the Short Form 36 Health Survey (SF-36) and the Inflammatory Bowel Disease Questionnaire (IBDQ-36). Logistic regression was performed to identify factors associated with HRQOL. RESULTS: The participation rate was 91.3%. Patients with IBD had a poorer HRQOL than the general population except on the Physical Function, Social Function, and Emotional Function Scale. Moreover, high levels of anxiety, depression, and stress were found to be associated with low levels in all quality of life measurements. No significant relationship was found between HRQOL and coping strategies. CONCLUSIONS: In patients with IBD, stress, anxiety and depression are important determinants of HRQOL and should therefore be considered in the management of this patient population.