Prophylactic oophorectomy rates in relation to a guideline update on referral to genetic counseling

Abstract

Objective We sought to determine whether prophylactic oophorectomy rates changed after the introduction of a 2007 health plan clinical guideline recommending systematic referral to a genetic counselor for women with a personal or family history suggestive of an inherited susceptibility to breast/ovarian cancer. Methods We conducted a retrospective cohort study of female members of Group Health, an integrated delivery system in Washington State. Subjects were women aged ≥35 years during 2004–2009 who reported a personal or family history consistent with an inherited susceptibility to breast/ovarian cancer. Personal and family history information was collected on a questionnaire completed when the women had a mammogram. We ascertained oophorectomies from automated claims data and determined whether surgeries were prophylactic by medical chart review. Rates were age-adjusted and age-adjusted incidence rate ratios (IRR) and 95% confidence intervals (CI) were computed using Poisson regression. Results Prophylactic oophorectomy rates were relatively unchanged after compared to before the guideline change, 1.0 versus 0.8/1,000 person-years, (IRR = 1.2; 95% CI: 0.7–2.0), whereas bilateral oophorectomy rates for other indications decreased. Genetic counseling receipt rates doubled after the guideline change (95% CI: 1.7–2.4) from 5.1 to 10.2/1,000 person-years. During the study, bilateral oophorectomy rates were appreciably greater in women who saw a genetic counselor compared to those who did not regardless of whether they received genetic testing as part of their counseling. Conclusion A doubling in genetic counseling receipt rates lends support to the idea that the guideline issuance contributed to sustained rates of prophylactic oophorectomies in more recent years.

Trends in BRCA Test Utilization in an Integrated Health System, 2005–2015

“…Medicare typically only covers testing for individuals with a personal cancer history, meaning some clinically eligible women may have had out-of-pocket costs (16). Since 2007, the health plan's breast cancer screening guideline has recommended providers screen women aged 25 years and older for HBOC risk and refer those with personal and family histories suggestive of inherited susceptibility to the Department of Genetic Services or Medical Oncology for counseling and discussion of testing (17,18).…”

Competing Risks for a Diagnosis of Invasive Breast Cancer

“…1 Although we do not have data to directly assess this issue, we believe that our findings are robust; this is an average-risk cohort, and very few women are likely to have received these interventions. [2][3][4][5] This view is supported by 4 observations. First, Pocobelli et al 3 assessed a cohort of 18 390 women, including a subcohort from our analysis, who were 35 years or older and reported a personal or family history consistent with an inherited susceptibility to breast and/or ovarian cancer between 2004 and 2009.…”

“…[2][3][4][5] This view is supported by 4 observations. First, Pocobelli et al 3 assessed a cohort of 18 390 women, including a subcohort from our analysis, who were 35 years or older and reported a personal or family history consistent with an inherited susceptibility to breast and/or ovarian cancer between 2004 and 2009. Those authors reported a low incidence rate for prophylactic oophorectomy of approximately 1 per 1000 person-years.…”

“…Revisiting the power calculation, the key determinants are the failure rate (events/ time) and rate ratio (ie, HR); thus, sample size was based on these quantities. At the planned total of 715 events for definitive analysis, power for HR of 0.77 would be 93% (using the Shoenfeld formula 3 ; an alternate determination that was based on time-varying event rates was used, yielding the original 90%). The same number of events would afford 80% power for an HR of 0.81 and 70% power for an HR of 0.83.…”

Competing Risks for a Diagnosis of Invasive Breast Cancer—Reply

“…1 Although we do not have data to directly assess this issue, we believe that our findings are robust; this is an average-risk cohort, and very few women are likely to have received these interventions. [2][3][4][5] This view is supported by 4 observations. First, Pocobelli et al 3 assessed a cohort of 18 390 women, including a subcohort from our analysis, who were 35 years or older and reported a personal or family history consistent with an inherited susceptibility to breast and/or ovarian cancer between 2004 and 2009.…”