Intraperitoneal cisplatin and paclitaxel versus intravenous carboplatin and paclitaxel chemotherapy for Stage III ovarian cancer: A cost-effectiveness analysis

Hysterectomy with sentinel lymph node dissection in the setting of preoperative endometrial intraepithelial neoplasia and an endometrial stripe ≥20 mm: a cost-effectiveness analysis

OBJECTIVES

Routine lymph node assessment in patients with endometrial intraepithelial neoplasia is institution and surgeon-dependent without clear guidelines. We sought to determine if routine sentinel lymph node (SLN) dissection at the time of laparoscopic hysterectomy for patients with a preoperative diagnosis of endometrial intraepithelial neoplasia and a preoperative ultrasound with endometrial stripe ≥20 mm is cost-effective.

METHODS

A decision model was created to perform two cost-effectiveness analyses: (1) hysterectomy with frozen section versus hysterectomy with SLN dissection in patients with a preoperative diagnosis of endometrial intraepithelial neoplasia and an endometrial stripe of 20 mm or greater, and (2) the same options in all patients with a preoperative diagnosis of endometrial intraepithelial neoplasia. Costs obtained from Centers for Medicare and Medicaid Services and event probabilities and quality of life utility values were obtained through literature review.

RESULTS

In the case of preoperative endometrial stripe ≥20 mm, hysterectomy with SLN dissection cost $2469 more than hysterectomy with frozen section and gained 0.010 quality adjusted life years, or $44,997/quality-adjusted life years gained. In one-way sensitivity analyses, SLN dissection remained the favored strategy at a willingness to pay threshold of $100,000/quality-adjusted life years unless chronic lower extremity lymphedema after full lymphadenectomy had a likelihood <13.1% (base case value 18.1%); otherwise, SLN dissection was favored with individual variation of all other parameters over plausible ranges. When considering all patients with endometrial intraepithelial neoplasia, hysterectomy with frozen section was favored, with results most sensitive to variation of lymphedema risk after full lymphadenectomy.

CONCLUSION

Hysterectomy with SLN dissection in patients with a preoperative endometrial stripe ≥20mm on ultrasound is cost-effective when compared with hysterectomy with frozen section.

Health state utility and health-related quality of life measures in patients with advanced ovarian cancer

Purpose

Measuring health-related quality of life (HRQoL) in ovarian cancer patients is critical to understand the impact of disease and treatment. Preference-based HRQoL measures, called health state utilities, are used specifically in health economic evaluations. Real-world patient-reported data on HRQoL and health state utilities over the long-term course of ovarian cancer are limited. This study aims to determine HRQoL and health state utilities in different health states of ovarian cancer.

Methods

This cross-sectional, multicenter study included patients with stage III-IV ovarian cancer in six health states: at diagnosis, during chemotherapy, after cytoreductive surgery (CRS), after chemotherapy, in remission, and at first recurrence. HRQoL was measured using the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C30, and the ovarian cancer-specific module OV28. Health state utilities were assessed using the EuroQol five-dimension five-level (EQ-5D-5L) questionnaire. Descriptive analyses were performed for each health state.

Results

Two hundred thirty-two patients participated, resulting in 319 questionnaires. Median age was 66 years. The lowest HRQoL was observed during chemotherapy and shortly after CRS. Physical and role functioning were most affected and the highest symptom prevalence was observed in the fatigue, nausea, pain, dyspnea, gastrointestinal, neuropathy, attitude, and sexuality domains. Patients in remission had the best HRQoL. Mean utility values ranged from 0.709 (±0.253) at diagnosis to 0.804 (±0.185) after chemotherapy.

Conclusions

This study provides clinicians with a valuable resource to aid in patient counseling and clinical decision-making. The utilities, in particular, are crucial for researchers conducting economic analyses to inform policy decisions.

Minimally invasive surgery for suspected early-stage ovarian cancer; a cost-effectiveness study

OBJECTIVE

While there are a number of benefits to minimally invasive surgery (MIS) for women with ovarian cysts, there is an increased risk of ovarian capsule rupture during the procedure, which could potentially seed the abdominal cavity with malignant cells. We developed a decision model to compare the risks, benefits, effectiveness and cost of MIS versus laparotomy in women with ovarian masses.

DESIGN

Cost-effectiveness study POPULATION: Hypothetical cohort of 10 000 women with ovarian masses who were undergoing surgical management.

METHODS

The initial decision point in the model was performance of surgery via laparotomy or a MIS approach. Model probabilities, costs and utility values were derived from published literature and administrative data sources. Extensive sensitivity analyses were conducted to assess the robustness of the findings.

MAIN OUTCOME MEASURES

The primary outcome was the cost-effectiveness of MIS versus laparotomy for women with a pelvic mass measured by incremental cost-effectiveness ratios (ICERs).

RESULTS

MIS was the least costly strategy at $7,732 per women on average, compared with $17,899 for laparotomy. In our hypothetical cohort of 10 000 women, there were 64 cases of ovarian rupture in the MIS group and 53 in the laparotomy group, while there were 26 cancer-related deaths in the MIS group and 25 in the laparotomy group. MIS was more effective than laparotomy (188 462 QALYs for MIS versus 187 631 quality adjusted life years [QALYs] for laparotomy). Thus, MIS was a dominant strategy, being both less costly and more effective than laparotomy. These results were robust in a variety of sensitivity analyses.

CONCLUSION

MIS constitutes a cost-effective management strategy for women with suspicious ovarian masses.

TWEETABLE ABSTRACT

MIS is a cost-effective management strategy for women with suspicious ovarian masses.

Practices of decision making in priority setting and resource allocation: a scoping review and narrative synthesis of existing frameworks

BACKGROUND

Due to growing expenditures, health systems have been pushed to improve decision-making practices on resource allocation. This study aimed to identify which practices of priority setting and resource allocation (PSRA) have been used in healthcare systems of high-income countries.

METHODS

A scoping literature review (2007-2019) was conducted to map empirical PSRA activities. A two-stage screening process was utilized to identify existing approaches and cluster similar frameworks. That was complemented with a gray literature and horizontal scanning. A narrative synthesis was carried out to make sense of the existing literature and current state of PSRA practices in healthcare.

RESULTS

One thousand five hundred eighty five references were found in the peer-reviewed literature and 25 papers were selected for full-review. We identified three major types of decision-making framework in PSRA: 1) Program Budgeting and Marginal Analysis (PBMA); 2) Health Technology Assessment (HTA); and 3) Multiple-criteria value assessment. Our narrative synthesis indicates these formal frameworks of priority setting and resource allocation have been mostly implemented in episodic exercises with poor follow-up and evaluation. There seems to be growing interest for explicit robust rationales and ample stakeholder involvement, but that has not been the norm in the process of allocating resources within healthcare systems of high-income countries.

CONCLUSIONS

No single dominate framework for PSRA appeared as the preferred approach across jurisdictions, but common elements exist both in terms of process and structure. Decision-makers worldwide can draw on our work in designing and implementing PSRA processes in their contexts.

Circular RNA circEXOC6B Inhibits the Progression of Ovarian Cancer by Sponging miR-421 and Regulating RUS1 Expression

Background

Evidence has been shown that circular RNAs (circRNAs) play a vital role during the development of ovarian cancer. However, the mechanism by which circEXOC6B regulates tumorigenesis of ovarian cancer remains unknown. Thus, this study aimed to investigate the role of circEXOC6B during the progression of ovarian cancer.

Materials and Methods

The dual-luciferase reporter system assay was used to determine the interaction between circEXOC6B, miR-421 and RUS1 in ovarian cancer, respectively. CCK8 and colony formatting were used to evaluate cell proliferation. Meanwhile, the expressions of RSU1, PINCH1 and ILK in SKOV3 cells were detected with Western blot.

Results

Downregulation of circEXOC6B markedly promoted the proliferation and invasion in A2780 cells. In contrast, upregulation of circEXOC6B significantly inhibited the proliferation and invasion in SKOV3 cells. Moreover, overexpression of circEXOC6B obviously induced the apoptosis of SKOV3 cells. Furthermore, luciferase reporter assay identified that miR-421 was the potential miRNA binding of circEXOC6B, and RUS1 was the potential binding target of miR-421. Mechanism analysis indicated that upregulation of circEXOC6B increased the level of RUS1 by acting as a competitive "sponge" of miR-421.

Conclusion

In this study, we found that circEXOC6B suppressed the growth of ovarian cancer cells through upregulating RSU1 partially via sponging miR-421. Therefore, circEXOC6B might be a potential target for the treatment of ovarian cancer.

Niraparib maintenance in frontline management of ovarian cancer: a cost effectiveness analysis

OBJECTIVES

Niraparib maintenance after frontline chemotherapy for advanced ovarian cancer extends progression free survival. The objective of this study was to determine the cost effectiveness of niraparib maintenance therapy in patients with newly diagnosed ovarian cancer.

METHODS

Decision analysis models compared the cost of observation versus niraparib maintenance following chemotherapy for five groups: all newly diagnosed ovarian cancer patients (overall), those with homologous recombination deficiency, those harboring BRCA mutations (BRCA), homologous recombination deficiency patients without BRCA mutations (homologous recombination deficiency non-BRCA), and non-homologous recombination deficiency patients. Drug costs were estimated using average wholesale prices. Progression free survival was estimated from published data and used to estimate projected overall survival. Incremental cost effectiveness ratios per quality adjusted life year were calculated. Sensitivity analyses varying the cost of niraparib were performed. The willingness-to-pay threshold was set at US$100 000 per quality adjusted life year saved.

RESULTS

For the overall group, the cost of observation was US$5.8 billion versus $20.5 billion for niraparib maintenance, with an incremental cost effectiveness ratio of $72 829. For the homologous recombination deficiency group, the observation cost was $3.0 billion versus $14.8 billion for niraparib maintenance (incremental cost effectiveness ratio $56 329). Incremental cost effectiveness ratios for the BRCA, homologous recombination deficiency non-BRCA, and non-homologous recombination deficiency groups were $58 348, $50 914, and $88 741, respectively. For the overall and homologous recombination deficiency groups, niraparib remained cost effective if projected overall survival was 2.2 and 1.5 times progression free survival, respectively.

CONCLUSIONS

For patients with newly diagnosed ovarian cancer, maintenance therapy with niraparib was cost effective. Cost effectiveness was improved when analyzing those patients with homologous recombination deficiency and BRCA mutations. Efforts should continue to optimize poly-ADP-ribose polymerase utilization strategies.

MicroRNA-32 promotes ovarian cancer cell proliferation and motility by targeting SMG1

Ovarian cancer (OC) is the most lethal gynecological malignancy and one of the leading causes of cancer-related deaths among women. Metastasis is the main cause of poor prognosis in OC. MicroRNA (miRNA/miR) has been shown to play an important role in tumorigenesis and metastasis in various cancer types by affecting the expression of its targets. In the present study, the role of miR-32 (miR-32-5p) in OC was explored. Reverse transcription-quantitative PCR results showed that miR-32 expression was significantly upregulated in both OC tissues and cell lines. Inhibition of miR-32 by transfection with miR-32 inhibitor in OC cells markedly suppressed cell proliferation, migration and invasion. In addition, a luciferase assay showed that suppressor of morphogenesis in genitalia 1 (SMG1) is a direct target of miR-32, and interference in SMG1 expression with transfection of SMG1 small hairpin RNA restored miR-32-mediated OC cell proliferation, migration and invasion. Taken together, these results indicate that miR-32 may promote OC cell growth and motility by targeting SMG1. The data of the present study suggest that miR-32 may serve as a potential therapeutic target for OC treatment in the future.

Glycogen phosphorylase B promotes ovarian cancer progression via Wnt/β-catenin signaling and is regulated by miR-133a-3p

BACKGROUND

Ovarian cancer is one of the most common gynecologic cancers with high morbidity and mortality in women. Glycogen metabolism plays a critical role in cancer development and glycogen phosphorylase B (PYGB) has reported to be involved in various tumors. Here, we explored the role of PYGB in ovarian cancer.

METHODS

PYGB mRNA expression were examined in ovarian cancer tissue and also analyzed using the dataset from The Cancer Genome Atlas cohort. Correlations between PYGB expression and prognosis of ovarian cancer patients were analyzed. PYGB was silenced to evaluate the ovarian cell proliferation, invasion and migration in vitro and tumorigenesis in vivo. MiR-133a-3p targeting PYGB was identified using online tools and confirmed with luciferase reporter experiment. MiR-133a-3p overexpression using miRNA mimics was conducted to evaluate its function on ovarian cancer cells.

RESULTS

We showed that PYGB was upregulated in ovarian cancer tissue and high level of PYGB expression is markedly correlated with poor prognosis of ovarian cancer patients. PYGB knockdown significantly suppressed ovarian cancer cell proliferation, invasion and migration. Xenograft tumor formation further demonstrated that knockdown PYGB inhibited ovarian tumor development. Bioinformatics analysis revealed that PYGB regulated Wnt/β-catenin signaling pathway in ovarian cancer cells. Mechanistically, miR-133a-3p directly bound to 3'-untranslated region of PYGB and overexpression miR-133a-3p suppressed proliferation, invasion and migration in ovarian cancer cells.

CONCLUSION

Our data suggest that miR-133a-3p/PYGB/Wnt-β-catenin axis plays a critical role in human ovarian cancer, which might serve as a promising therapeutic target of ovarian cancer treatment in the future.

Assessing value in health care: using an interpretive classification system to understand existing practices based on a systematic review

BACKGROUND

Implementing adequate strategies to assess the value of health services plays a central role in the effort to deal with the financial pressures faced by health care systems worldwide. This study aimed to understand which approaches to value assessment have been used in developed countries.

METHODS

We conducted a rapid review and a gray literature search to identify value assessment frameworks. A two-stage screening process was utilized to identify existing approaches and cluster similar frameworks. In addition, we developed an interpretive classification system to make sense of existing approaches.

RESULTS

One thousand one hundred seventy-six references were identified and 38 papers were selected for full-review. Among these 38 articles, 22 distinct approaches to assess value of health care interventions were identified and classified according to four points: 1) use of single or multiple considerations to base value estimates; 2) use of disease-specific or generic criteria; 3) reliance on process-based or outcomes-based consideration; and 4) type of input and evidence considered.

CONCLUSIONS

The contextual nature of value assessment in health care becomes evident with the diversity of existing approaches. Despite the predominance of cases relying on the Incremental cost-effectiveness ratio as the measure of value, this approach has not been sufficient to meet the needs of decision-makers. The use of multiple criteria has become more and more important, as well as the consideration of patient-reported measures. Considerations of costs are not always explicit and consistent.

Do current approaches to assessing therapy related adverse events align with the needs of long-term cancer patients and survivors?

The increasing efficacy of cancer therapeutics means that the timespan of cancer therapy administration is undergoing a transition to increasingly long-term settings. Unfortunately, chronic therapy-related adverse health events are an unintended, but not infrequent, outcome of these life-saving therapies. Historically, the cardio-oncology field has evolved as retrospective effort to understand the scope, mechanisms, and impact of treatment-related toxicities that were already impacting patients. This review explores whether current systemic approaches to detecting, reporting, tracking, and communicating AEs are better positioned to provide more proactive or concurrent information to mitigate the impact of AE's on patient health and quality of life. Because the existing tools and frameworks for capturing these effects are not specific to cardiology, this study looks broadly at the landscape of approaches and assumptions. This review finds evidence of increasing focus on the provision of actionable information to support long-term health and quality of life for survivors and those on chronic therapy. However, the current means to assess and support the impact of this burden on patients and the healthcare system are often of limited relevance for an increasingly long-lived survivor and patient population.

ASCO Value Framework Highlights the Relative Value of Treatment Options in Ovarian Cancer

PURPOSE

The ASCO value framework allows physicians and patients to compare the relative value of novel treatments. Our aim was to assess the value of three frontline ovarian cancer therapies by using this framework.

METHODS

From phase III, randomized controlled clinical trial (RCT) data, the net health benefits (NHBs) for three frontline ovarian cancer treatment options-dose-dense paclitaxel (Japanese Gynecologic Oncology Group study JGOG 3016), intraperitoneal (IP)/intravenous (IV) chemotherapy (Gynecologic Oncology Group [GOG] study GOG 172), and concurrent plus maintenance bevacizumab (GOG 218 and the Seventh International Collaborative Ovarian Neoplasm study [ICON7])-were calculated. The ASCO value framework calculates the NHB by using six criteria: clinical benefit, toxicity, tail of the curve, symptom palliation, treatment-free interval, and quality of life. Clinical benefit calculation uses ASCO-assigned importance weights for overall survival and progression-free survival. The maximum possible NHB points is 180. NHBs were presented alongside the drug-acquisition cost (DAC) of each therapy. A benefit-cost ratio of NHB points per additional cost was calculated.

RESULTS

The NHB of dose-dense paclitaxel was 38, at an additional cost of $16 per cycle. IP cisplatin/IV + IP paclitaxel received 29 NHB points, at an additional cost of $1,629 per cycle. Concurrent plus maintenance bevacizumab received 24 NHB points, at an additional cost of $7,581 per cycle (GOG 218) or six NHB points ($3,790 per cycle; ICON7). The ratios of NHB points-to-dollar were as follows: dose-dense paclitaxel, 2.4 (highest); IP chemotherapy, 0.018; and bevacizumab, 0.003 (lowest).

CONCLUSION

Using the ASCO value framework, we constructed value snapshots of three major frontline therapeutic options in ovarian cancer. Dose-dense paclitaxel provided the highest additional value when analysis accounted for NHB and cost. However, additional research is needed to include individual patient preferences and provide personalized value assessments.

Bevacizumab in ovarian cancer: A critical review of phase III studies

Bevacizumab (BV) is a humanized monoclonal antibody targeting vascular endothelial growth factor and it is the first molecular-targeted agent to be used for the treatment of ovarian cancer (OC). Randomized Phase III trials evaluated the combination of BV plus standard chemotherapy for first-line treatment of advanced OC and for platinum-sensitive and platinum-resistant recurrent OC. These trials reported a statistically significant improvement in progression-free survival but not in overall survival. Furthermore, BV effectively improved the quality of life with regard to abdominal symptoms in recurrent OC patients. Bevacizumab is associated with adverse events such as hypertension, bleeding, thromboembolism, proteinuria, delayed wound healing, and gastrointestinal events. However, most of these events can be adequately managed. This review describes the latest evidence for BV treatment of OC and selection of patients for personalized treatment.

Targeted nanoparticles for head and neck cancers: overview and perspectives

Head and neck cancer (HNC) is common in several regions and is associated with high morbidity and mortality worldwide. This review summarizes the recent progress in the development of targeted nanoparticle systems for HNC therapy. WIREs Nanomed Nanobiotechnol 2017, 9:e1469. doi: 10.1002/wnan.1469 For further resources related to this article, please visit the WIREs website.

Cost-effectiveness of primary debulking surgery when compared to neoadjuvant chemotherapy in the management of stage IIIC and IV epithelial ovarian cancer

OBJECTIVES

To examine the cost-effectiveness of primary debulking surgery (PDS) when compared to neoadjuvant chemotherapy (NACT) in the management of epithelial ovarian cancer (EOC) using Surveillance, Epidemiology, and End Results data linked to Medicare claims (SEER-Medicare).

METHODS

Using a Markov model, the cost-effectiveness of PDS was compared to that of NACT. We modeled cost and survival inputs using data from women in the SEER-Medicare database with ovarian cancer treated by either PDS or NACT between 1992 and 2009. Direct and indirect costs were discounted by an annual rate of 3%. Utility weights were obtained from published data. The incremental cost-effectiveness ratio (ICER) of PDS compared to NACT was calculated.

RESULTS

In our model, women with stage IIIC EOC had a higher mean adjusted treatment cost for PDS when compared to NACT ($31,945 vs $30,016) but yielded greater quality-adjusted life-years (QALYs) (1.79 vs 1.69). The ICER was $19,359/QALY gained. Women with stage IV EOC had a higher mean adjusted treatment cost following PDS when compared to NACT ($31,869 vs $27,338) but yielded greater QALYs (1.69 vs 1.66). The ICER was $130,083/QALY gained. A sensitivity analysis showed that for both PDS and NACT the ICER was sensitive to incremental changes in the utility weight.

CONCLUSION

PDS is significantly more cost-effective for women with stage IIIC when compared to NACT. In women with stage IV EOC, PDS is also more cost-effective though the QALYs gained are much more costly and exceed a $50,000 willingness to pay.

A noticeable difference? Productivity costs related to paid and unpaid work in economic evaluations on expensive drugs

Productivity costs can strongly impact cost-effectiveness outcomes. This study investigated the impact in the context of expensive hospital drugs. This study aimed to: (1) investigate the effect of productivity costs on cost-effectiveness outcomes, (2) determine whether economic evaluations of expensive drugs commonly include productivity costs related to paid and unpaid work, and (3) explore potential reasons for excluding productivity costs from the economic evaluation. We conducted a systematic literature review to identify economic evaluations of 33 expensive drugs. We analysed whether evaluations included productivity costs and whether inclusion or exclusion was related to the study population's age, health and national health economic guidelines. The impact on cost-effectiveness outcomes was assessed in studies that included productivity costs. Of 249 identified economic evaluations of expensive drugs, 22 (9 %) included productivity costs related to paid work. One study included unpaid productivity. Mostly, productivity cost exclusion could not be explained by the study population's age and health status, but national guidelines appeared influential. Productivity costs proved often highly influential. This study indicates that productivity costs in economic evaluations of expensive hospital drugs are commonly and inconsistently ignored in economic evaluations. This warrants caution in interpreting and comparing the results of these evaluations.

Polymeric nanoparticles for colon cancer therapy: overview and perspectives

Colorectal cancer (CRC) is the third-most common malignant tumour and is associated with high morbidity and mortality worldwide.

Cost-Effectiveness of Chemotherapy for Breast Cancer and Age Effect in Older Women

BACKGROUND

Previous economic evaluations compared specific chemotherapy agents using input parameters from clinical trials and resource utilization costs. Cost-effectiveness of treatment groups (drug classes) using community-level effectiveness and cost data, however, has not been assessed for elderly patients with breast cancer.

OBJECTIVE

To assess the cost-effectiveness of chemotherapy regimens by age and disease stage under "real-world" conditions for patients with breast cancer.

METHODS

The Surveillance Epidemiology and End Results-Medicare data were used to identify patients with breast cancer with American Joint Committee on Cancer stage I/II/IIIa, hormone receptor-negative (estrogen receptor-negative and progesterone receptor-negative) patients from 1992 to 2009. Patients were categorized into three adjuvant treatment groups: 1) no chemotherapy, 2) anthracycline, and 3) non-anthracycline-based chemotherapy. Median life-years and quality-adjusted life-years (QALYs) were measured using Kaplan-Meier analysis and were evaluated against average total health care costs (2013 US dollars).

RESULTS

A total of 4575 patients (propensity score-matched) were included for the primary analysis. The anthracycline group experienced 12.05 QALYs and mean total health care costs of $119,055, resulting in an incremental cost-effectiveness ratio of $7,688 per QALY gained as compared with the no chemotherapy group (QALYs 7.81; average health care cost $86,383). The non-anthracycline-based group was dominated by the anthracycline group with lower QALYs (9.56) and higher health care costs ($122,791). Base-case results were found to be consistent with the best-case and worst-case scenarios for utility assignments. Incremental cost-effectiveness ratios varied by age group (range $3,790-$90,405 per QALY gained).

CONCLUSIONS

Anthracycline-based chemotherapy was found cost-effective for elderly patients with early stage (stage I, II, IIIa) breast cancer considering the US threshold of $100,000 per QALY. Further research may be needed to characterize differential effects across age groups.

Cost Effectiveness of Chemotherapeutic Agents and Targeted Biologics in Ovarian Cancer: A Systematic Review

BACKGROUND

Adjuvant chemotherapy is a key component of advanced ovarian cancer treatment, when surgery alone is not sufficient. Recurrence is common in ovarian cancer patients and most women require prolonged second-line and higher-line chemotherapy. With newer targeted therapies, modest improvements in survival and quality of life may be attained at substantial cost, but the relative economic efficiency of these newer agents remains unknown.

OBJECTIVE

We undertook this systematic review to comprehensively evaluate the cost-effectiveness of various chemotherapeutic and targeted therapy alternatives for ovarian cancer.

METHODS

We searched Medline, PubMed, and Embase databases to identify economic evaluations published over the last 18 years (1996-2014). From the 2513 unique papers retrieved, 74 full texts were selected for full-text review based on a priori eligibility criteria. Two authors independently reviewed these articles to determine eligibility for final review. The quality of the included studies was assessed using the Quality of Health Economic Studies (QHES).

RESULTS

A total of 28 studies were included for reporting. Administration of intravenous cisplatin-paclitaxel combination chemotherapy for first-line treatment was the most cost-effective alternative (2014 US dollars [USD] equivalent incremental cost-effectiveness ratio [ICER] ~US$17,000-US$27,000 per life year gained [LYG]), while the use of bevacizumab did not demonstrate similar value for money (2014 USD equivalent ICER was greater than US$200,000 per quality-adjusted life-year [QALY]). For second-line treatment, the use of platinum-paclitaxel combination or platinum monotherapy was cost-effective compared with platinum monotherapy or best supportive care, respectively, in women with recurrent platinum-sensitive disease. For patients with partial platinum sensitivity, pegylated liposomal doxorubicin (PLD) plus trabectedin may be cost-effective (2014 USD equivalent ICER was ~US$57,000-US$62,000 per QALY) compared with PLD alone. For recurrent platinum-resistant cases, there was limited evidence to conclude the most valuable treatment; though one study showed that best supportive care was most cost-effective, while second-line monotherapy with doxorubicin (2014 USD equivalent ICER was ~US$90,000 per LYG) may also be cost-effective compared with best supportive care.

CONCLUSIONS

Despite varying methodological approaches and multiple sources for cost and effectiveness inputs, this systematic review demonstrated that standard platinum-taxane combination chemotherapy for first-line treatment was most cost-effective. There was unanimous agreement that bevacizumab was not a cost-effective front-line therapy compared with platinum-taxane combination for the overall ovarian cancer population, though its use in the high-use population may yield better value. For second-line treatment, platinum-based chemotherapy remained cost-effective among patients with recurrent platinum-sensitive disease, while there was limited evidence to conclude the most valuable treatment alternative among patients with recurrent platinum-resistant disease. Future research incorporating real-world data is essential to corroborate findings from trial-based economic evaluations. In addition, for improving consistency in reporting and quality of studies, incorporating QALYs in this population is important, especially since chemotherapy is administered for lengthy periods of time.

Topotecan, pegylated liposomal doxorubicin hydrochloride, paclitaxel, trabectedin and gemcitabine for advanced recurrent or refractory ovarian cancer: a systematic review and economic evaluation

BACKGROUND

Ovarian cancer is the fifth most common cancer in the UK, and the fourth most common cause of cancer death. Of those people successfully treated with first-line chemotherapy, 55-75% will relapse within 2 years. At this time, it is uncertain which chemotherapy regimen is more clinically effective and cost-effective for the treatment of recurrent, advanced ovarian cancer.

OBJECTIVES

To determine the comparative clinical effectiveness and cost-effectiveness of topotecan (Hycamtin(®), GlaxoSmithKline), pegylated liposomal doxorubicin hydrochloride (PLDH; Caelyx(®), Schering-Plough), paclitaxel (Taxol(®), Bristol-Myers Squibb), trabectedin (Yondelis(®), PharmaMar) and gemcitabine (Gemzar(®), Eli Lilly and Company) for the treatment of advanced, recurrent ovarian cancer.

DATA SOURCES

Electronic databases (MEDLINE(®), EMBASE, Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluations Database) and trial registries were searched, and company submissions were reviewed. Databases were searched from inception to May 2013.

METHODS

A systematic review of the clinical and economic literature was carried out following standard methodological principles. Double-blind, randomised, placebo-controlled trials, evaluating topotecan, PLDH, paclitaxel, trabectedin and gemcitabine, and economic evaluations were included. A network meta-analysis (NMA) was carried out. A de novo economic model was developed.

RESULTS

For most outcomes measuring clinical response, two networks were constructed: one evaluating platinum-based regimens and one evaluating non-platinum-based regimens. In people with platinum-sensitive disease, NMA found statistically significant benefits for PLDH plus platinum, and paclitaxel plus platinum for overall survival (OS) compared with platinum monotherapy. PLDH plus platinum significantly prolonged progression-free survival (PFS) compared with paclitaxel plus platinum. Of the non-platinum-based treatments, PLDH monotherapy and trabectedin plus PLDH were found to significantly increase OS, but not PFS, compared with topotecan monotherapy. In people with platinum-resistant/-refractory (PRR) disease, NMA found no statistically significant differences for any treatment compared with alternative regimens in OS and PFS. Economic modelling indicated that, for people with platinum-sensitive disease and receiving platinum-based therapy, the estimated probabilistic incremental cost-effectiveness ratio [ICER; incremental cost per additional quality-adjusted life-year (QALY)] for paclitaxel plus platinum compared with platinum was £24,539. Gemcitabine plus carboplatin was extendedly dominated, and PLDH plus platinum was strictly dominated. For people with platinum-sensitive disease and receiving non-platinum-based therapy, the probabilistic ICERs associated with PLDH compared with paclitaxel, and trabectedin plus PLDH compared with PLDH, were estimated to be £25,931 and £81,353, respectively. Topotecan was strictly dominated. For people with PRR disease, the probabilistic ICER associated with topotecan compared with PLDH was estimated to be £324,188. Paclitaxel was strictly dominated.

LIMITATIONS

As platinum- and non-platinum-based treatments were evaluated separately, the comparative clinical effectiveness and cost-effectiveness of these regimens is uncertain in patients with platinum-sensitive disease.

CONCLUSIONS

For platinum-sensitive disease, it was not possible to compare the clinical effectiveness and cost-effectiveness of platinum-based therapies with non-platinum-based therapies. For people with platinum-sensitive disease and treated with platinum-based therapies, paclitaxel plus platinum could be considered cost-effective compared with platinum at a threshold of £30,000 per additional QALY. For people with platinum-sensitive disease and treated with non-platinum-based therapies, it is unclear whether PLDH would be considered cost-effective compared with paclitaxel at a threshold of £30,000 per additional QALY; trabectedin plus PLDH is unlikely to be considered cost-effective compared with PLDH. For patients with PRR disease, it is unlikely that topotecan would be considered cost-effective compared with PLDH. Randomised controlled trials comparing platinum with non-platinum-based treatments might help to verify the comparative effectiveness of these regimens.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003555.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Cost-Effectiveness of Neoadjuvant Chemotherapy versus Primary Surgery in Elderly Patients with Advanced Ovarian Cancer

BACKGROUND

The use of neoadjuvant chemotherapy (NAC) in the treatment of advanced ovarian cancer has increased in recent years. There is uncertainty about NAC's effectiveness and no study of its cost-effectiveness compared with that of standard primary debulking surgery (PDS).

OBJECTIVES

To seek answers to three important questions: 1) What is the lifetime cost of treating elderly patients with advanced ovarian cancer, based on the primary treatment received? 2) Are the extra costs expended by the NAC group worth any extra survival advantage? 3) Would NAC potentially benefit a particular subgroup and serve as a cost-effective first-line treatment approach?

METHODS

A cohort of elderly women (≥65 years) with stage III/IV ovarian cancer was identified from the Surveillance, Epidemiology and End Results-Medicare linked database from January 1, 2000, to December 31, 2009. Cost analysis was conducted from a payer perspective, and direct medical costs incurred by Medicare were integrated for each patient. Cumulative treatment costs were estimated with a phase-of-care approach, and effectiveness was measured as years of survival. Incremental cost-effectiveness ratio (ICER) and propensity-score-adjusted net monetary benefit regression was used to estimate the cost-effectiveness of NAC per life-year gained. Analyses were further stratified by risk group categorization on the basis of tumor stage, patient age, and comorbidity score.

RESULTS

Average lifetime cost for treatment with NAC was $17,417 more than with PDS. With only 0.1 incremental life-year gained, the ICER estimate was $174,173. Stratification, however, helped to delineate the treatment effect. Patients in the high-risk subgroup incurred $34,390 and 0.8 life-years more than did patients in the PDS subgroup, with a corresponding ICER of $42,987. In the non-high-risk subgroup, NAC use was dominated by PDS (more costly, less effective).

CONCLUSIONS

Administering NAC before surgery to patients in the high-risk subgroup was cost-effective at "normal" levels of willingness to pay, but not for the overall sample or for patients in the non-high-risk subgroup.

Cost-effectiveness of early-initiated treatment for advanced-stage epithelial ovarian cancer patients: a modeling study

OBJECTIVE

Between diagnosis and primary treatment of patients with epithelial ovarian cancer (EOC), gaps of several weeks exist. Reducing these time intervals may benefit the patient and may lead to a reduction of costs. We explored the cost-effectiveness of early-initiated treatment of patients with suspected advanced-stage EOC compared with that of current treatment.

METHODS

A discrete event simulation was used to synthesize all available evidences and to evaluate the health care costs and effects (quality-adjusted life years [QALYs]) of the 2 treatment strategies over lifetime. Overall survival, progression-free survival, health-related quality of life, and costs of the separate events were assumed to remain equal. Other uncertainties were addressed using deterministic and probabilistic sensitivity analyses.

RESULTS

The treatment times of current and early-initiated treatment were 27 and 24 weeks, respectively. Early-initiated treatment yielded 3.42 QALYs per patient, for a total expected health care cost of €25,654. Current treatment yielded 3.40 QALYs per patient, for a total expected health care cost of €25,607. This resulted in an incremental cost-effectiveness ratio of €2592 per QALY gained for early-initiated treatment compared with that for current treatment. For the willingness to pay for €30,000 or more per QALY, early-initiated treatment had a 100% probability of being cost-effective compared with current treatment under the previously mentioned assumptions.

CONCLUSIONS

Given the current evidence, early-initiated treatment of patients with suspected advanced-stage EOC leads to additional QALYs and seems to be cost-effective compared with current treatment.

Bevacizumab in treatment of high-risk ovarian cancer--a cost-effectiveness analysis

The objective of this study was to evaluate a cost-effectiveness strategy of bevacizumab in a subset of high-risk advanced ovarian cancer patients with survival benefit. Methods. A subset analysis of the International Collaboration on Ovarian Neoplasms 7 trial showed that additions of bevacizumab (B) and maintenance bevacizumab (mB) to paclitaxel (P) and carboplatin (C) improved the overall survival (OS) of high-risk advanced cancer patients. Actual and estimated costs of treatment were determined from Medicare payment. Incremental cost-effectiveness ratio per life-year saved was established. Results. The estimated cost of PC is $535 per cycle; PCB + mB (7.5 mg/kg) is $3,760 per cycle for the first 6 cycles and then $3,225 per cycle for 12 mB cycles. Of 465 high-risk stage IIIC (>1 cm residual) or stage IV patients, the previously reported OS after PC was 28.8 months versus 36.6 months in those who underwent PCB + mB. With an estimated 8-month improvement in OS, the incremental cost-effectiveness ratio of B was $167,771 per life-year saved. Conclusion. In this clinically relevant subset of women with high-risk advanced ovarian cancer with overall survival benefit after bevacizumab, our economic model suggests that the incremental cost of bevacizumab was approximately $170,000.

Can we maximize both value and quality in gynecologic cancer care? A work in progress

Value is defined as desirable health outcomes achieved per monetary unit spent. Comparative effectiveness research and cost-effectiveness research are methods that have been developed to quantify effectiveness and value to inform management decisions. In this article we review the comparative and cost-effectiveness literature in the field of ovarian cancer treatment. Studies have shown that improved ovarian cancer survival is associated with complete primary surgical cytoreduction, with treatment at high volume facilities by subspecialist providers (gynecologic oncologists) and with National Comprehensive Cancer Network (NCCN) guideline-adherent care in both surgical staging and chemotherapy regimens. Intraperitoneal/intravenous chemotherapy (compared with intravenous alone) has been associated with improved survival and cost-effectiveness. Bevacizumab for primary and maintenance therapy has been found to not be cost-effective (even in selective subsets) despite a small progression-free survival (PFS) advantage. For platinum-sensitive recurrent ovarian cancer, secondary cytoreduction and platinum-based combinations are associated with improved overall survival (OS); several platinum-based combinations have also been found cost-effective. For platinum-resistant recurrence, single agent therapy and supportive care are cost-effective compared with combination therapies. Although little prospective clinical research has been done around end-of-life care, one study reported that for platinum-resistant ovarian cancer, palliative intervention would potentially reduce costs and increase quality adjusted life years compared with usual care (based on improvement in quality of life [QOL]). Overall, cost comparisons of individual chemotherapy regimens are highly dependent on market prices of novel therapeutic agents.

Cost-utility analysis of platinum-based chemotherapy versus taxane and other regimens for ovarian cancer

OBJECTIVES

Most economic evaluations of chemotherapies for ovarian cancer patients have used hypothetical cohorts or randomized control trials, but evidence integrating real-world survival, cost, and utility data is limited.

METHODS

A propensity score-matched cohort of 6856 elderly (≥65 years) ovarian cancer patients diagnosed from 1991 to 2005 from the Surveillance, Epidemiology, and End Results-Medicare data cohort were included. Treatment regimens (i.e., no chemotherapy, platinum-based only, platinum plus taxane, and other nonplatinum) were identified in the 6 months postdiagnosis. Patients were followed until death or end of study (December 2006). Effectiveness was measured in quality-adjusted life-years (QALYs), and total health care costs were measured by using a payer's perspective (2009 US dollars). Methodological and statistical uncertainties were accounted by including alternative scenarios (for utility values) and net monetary benefit approach. Incremental cost-effectiveness ratios (ICERs) were calculated, and stratified analyses were performed by tumor stages and age groups.

RESULTS

On comparing the platinum-based group versus no chemotherapy, we found that the ICER was $30,073/QALY and $58,151/QALY for early- and late-stage disease, respectively, while other nonplatinum and platinum plus taxane groups were dominated (less effective and more costly). Similar results were found across alternative scenarios and age groups. For patients 85 years or older, platinum plus taxane, however, was not dominated by the platinum-based group, with an ICER of $133,892/QALY.

CONCLUSIONS

Following elderly ovarian cancer patients over a lifetime using real-world longitudinal data and adjusting for quality of life, we found that treatment with platinum-based regimen was the most cost-effective treatment alternative.

Are the true impacts of adverse events considered in economic models of antineoplastic drugs? A systematic review

BACKGROUND

Antineoplastic drugs for cancer are often associated with adverse events, which influence patients' physical health, quality of life and survival. However, the modelling of adverse events in cost-effectiveness analyses of antineoplastic drugs has not been examined.

AIMS

This article reviews published economic evaluations that include a calculated cost for adverse events of antineoplastic drugs. The aim is to identify how existing models manage four issues specific to antineoplastic drug adverse events: the selection of adverse events for inclusion in models, the influence of dose modifications on drug quantity and survival outcomes, the influence of adverse events on quality of life and the consideration of multiple simultaneous or recurring adverse events.

METHODS

A systematic literature search was conducted using MESH headings and key words in multiple electronic databases, covering the years 1999-2009. Inclusion criteria for eligibility were papers covering a population of adults with solid tumour cancers, the inclusion of at least one adverse event and the resource use and/or costs of adverse event treatment.

RESULTS

From 4,985 citations, 26 eligible articles were identified. Studies were generally of moderate quality and addressed a range of cancers and treatment types. While the four issues specific to antineoplastic drug adverse events were addressed by some studies, no study addressed all of the issues in the same model.

CONCLUSION

This review indicates that current modelling assumptions may restrict our understanding of the true impact of adverse events on cost effectiveness of antineoplastic drugs. This understanding could be improved through consideration of the selection of adverse events, dose modifications, multiple events and quality of life in cost-effectiveness studies.

Increased elimination of paclitaxel by magnesium isoglycyrrhizinate in epithelial ovarian cancer patients treated with paclitaxel plus cisplatin: a pilot clinical study

Magnesium isoglycyrrhizinate (MI) has been complementarily used for restoring the hepatic impairments caused by taxol plus platinum based chemotherapies in China. Due to the hepatic dependence of paclitaxel elimination, this pilot clinical study aimed to investigate the influence of MI on the pharmacokinetics of paclitaxel in epithelial ovarian cancer patients. During the standard chemotherapy of intravenous paclitaxel (125 mg/m(2) infused over a 3-h period) and intraperitoneal cisplatin (60 mg/m(2)) for patients with FIGO stage II epithelial ovarian cancer, 9 each of total 18 patients were respectively treated with intravenous MI (100 mg) or vehicle control for 4 days. Plasma paclitaxel was analyzed by HPLC and the pharmacokinetic parameters were calculated with non-compartmental analysis. The hematological, hepatic and renal status was monitored before and 3 days after paclitaxel administration. It was observed the terminal t 1/2 and MRT of paclitaxel were significantly (p = 0.002 and 0.001) reduced by MI, respectively, from 11.0 ± 2.2 and 5.6 ± 1.0 h to 7.7 ± 1.7 and 4.0 ± 0.3 h. Hematological toxicity indicated by platelet count and hepatic events marked with ALT, AST and γ-GT were significant in both groups. In spite of the insignificance of decreased system exposure of paclitaxel and recovered hepatic function by MI, they did correlate with each other. It was therefore deduced that the liver toxicities of paclitaxel plus cisplatin chemotherapy potentially decrease hepatic elimination and increase system exposure of paclitaxel, and the recovery of liver function by MI helps to restore hepatic clearance of paclitaxel. The clinical significance of this pharmacokinetic interaction requires further studies with larger population size.

Comparison of methods to estimate health state utilities for ovarian cancer using quality of life data: a Gynecologic Oncology Group study

BACKGROUND

Cost-effectiveness/cost-utility analyses are increasingly needed to inform decisions about care. Algorithms have been developed using the Functional Assessment of Cancer Therapy (FACT) quality of life instrument to estimate utility weights for cost analyses. This study was designed to compare these algorithms in the setting of ovarian cancer.

METHODS

GOG-0152 was a 550-patient randomized phase III trial of interval cytoreduction, and GOG-0172 was a 415-patient randomized phase III trial comparing intravenous versus intraperitoneal therapy among women with advanced ovarian cancer. QOL data were collected via the FACT at four time points in each study. Two published mapping algorithms (Cheung and Dobrez) and a linear transformation method were applied to these data. The agreement between measures was assessed by the concordance correlation coefficient (r(CCC)), and paired t-tests were used to compare means.

RESULTS

While agreement between the estimation algorithms was good (ranged from 0.72 to 0.81), there were statistically significant (p<0.001) and clinically meaningful differences between the scores: mean scores were higher with Dobrez than with Cheung or the linear transformation method. Scores were also statistically significantly different (p<0.001) between studies.

CONCLUSIONS

In the absence of prospectively collected utility data, the use of mapping algorithms is feasible, however, the optimal algorithm is not clear. There were significant differences between studies, which highlight the need for validation of these algorithms in specific settings. If cost analyses incorporate mapping algorithms to obtain utility estimates, investigators should take the variability into account.

Comparative effectiveness of platinum-based chemotherapy versus taxane and other regimens for ovarian cancer

The aim was to compare the two most commonly recommended chemotherapy regimens (platinum-based chemotherapy and platinum-taxane combination) with non-platinum-based chemotherapy and those with no chemotherapy in a large nationwide and population-based cohort of patients with ovarian cancer with up to 17 years of follow-up. We studied 12,181 patients diagnosed with stages I-IV ovarian cancer at age ≥ 65 in 1991-2005 from the 16 areas of the United States. We also performed matched cohort analyses based on conditional probability of receiving platinum chemotherapy in 3,428 patients. In patients with early stage ovarian cancer, those who received platinum-taxane combination had the highest 5-year all-cause (62.5 %) and cancer-specific (65.1 %) survival rates, as compared to 51.5 and 63.7 % in those without chemotherapy. After adjusting for potential confounders, hazard ratios of all-cause mortality (0.66, 95 % CI 0.55-0.79) and cancer-specific mortality (0.74, 0.61-0.90) were significantly lower in patients receiving platinum-taxane combination as compared to those without chemotherapy. Among patients with late-stage ovarian cancer, risks of mortality were significantly reduced in patients who received both platinum and taxane (0.38, 0.36-0.41 for all-cause mortality; 0.40, 0.37-0.42 for cancer-specific mortality). Dose-response relationship appeared strong within each of the three chemotherapy regimens. These results and trends were almost identical in the matched cohort. Platinum-taxane combination chemotherapy and platinum-based chemotherapy without taxane were effective in prolonging survival with a significant dose-response relationship among patients with late-stage ovarian cancer. Among those with early stage tumors, platinum-taxane combination appeared more effective than other chemotherapy regimens.

Establishment, characterization and downstream application of primary ovarian cancer cells derived from solid tumors

Ovarian cancer is the deadliest of the gynecological diseases and the fifth cause of cancer death among American women. This is mainly due to the lack of prognostic tools capable of detecting early stages of ovarian cancer and to the high rate of resistance to the current chemotherapeutic regimens. In this scenario the overall 5-year survival rate for ovarian cancer patients diagnosed at late stage is less than 25%. Abnormalities associated with the malignant phenotype and the mechanisms of tumor progression are not clearly understood. In vitro studies are necessary, yet have been hampered due to the limitations accompanied with the use of ovarian cancer cell lines and the heterogeneity of the ovarian cancer cell population derived from ascites fluids. In this study we present a simple, rapid and reproducible method for the isolation and characterization of ovarian cancer cells from solid tumor tissue and show that enzymatic digestion for 30 minutes with dispase II results in the most effective recovery of viable epithelial ovarian cancer (EOC) cells. The resulting cancer (EOC) cell preparations demonstrate a significant yield, high levels of viability and are fibroblast-free. They grow for up to six passages and retain the capacity of forming spheroids-like structures in agarose. In addition, they can be genetically manipulated and used for drug screening, thus rendering them highly suitable for downstream applications. Notably, isolation of ovarian cancer cells from solid specimens using this method has the advantage of allowing for isolation of cancer cells from early stages of ovarian cancer as well as obtaining cells from defined either primary and/or metastatic ovarian cancer sites. Thus, these cells are highly suitable for investigations aimed at understanding ovarian cancer.

Clinical utility of targeted treatments in the management of epithelial ovarian cancer

Epithelial ovarian cancer is typically found in its advanced stages, where a combination of surgical debulking and platinum/taxane-based chemotherapy is recommended. Although over 70%-80% of patients achieve remission, a significant proportion develop recurrence of their disease. Additional cytotoxic chemotherapy, as well as surgery, is typically used to manage disease recurrence. Therapies that target specific pathways in cancer cells are rapidly developing in the laboratory and are increasingly being studied in patients with ovarian cancer. We review the current status of novel therapies in the management of epithelial ovarian cancer.

An economic analysis of dose dense weekly paclitaxel plus carboplatin versus every-3-week paclitaxel plus carboplatin in the treatment of advanced ovarian cancer

OBJECTIVE

Compared with every-3-week paclitaxel (q3T) plus carboplatin, dose-dense weekly paclitaxel (ddT) plus carboplatin improved the survival of ovarian cancer patients. We performed a cost analysis comparing these two regimens.

METHODS

Using a Markov decision model, an acceptable incremental cost-effectiveness ratio (ICER) per progression-free life-year saved (PFLYS) was estimated. Cost of drugs, growth colony-stimulating factors, and transfusions were derived from Medicare reimbursement data. Survival and rates of complications were estimated based on the clinical trial.

RESULTS

Using a body weight and surface area of an average woman age 63, the estimated cost per cycle of ddT was $107 vs. $80 for q3T. The costs per cycle of combination chemotherapy including treatment administration were $873 for ddT and $535 for q3T. With a median progression-free survival (PFS) of 28 months with ddT vs. 17.2 months with q3T, the ICER was $5809 per PFLYS for ddT compared with q3T arm. Using a maximum ICER of $100,000 per LYS as cost-effective threshold, the ddT regimen was cost-effective. The ICER was most sensitive to the hazard rate for difference in PFS between the two regimens. A 4-month difference in PFS resulted in a $1200 change of ICER per PFLYS. The ICER was also sensitive to overall survival difference, rate of hematological toxicity, and rate of discontinuation.

CONCLUSIONS

In this economic model, dose-dense weekly paclitaxel is a cost-effective treatment option for advanced ovarian cancer.

New players in ovarian cancer

Ovarian cancer is the leading cause of gynecologic cancer mortality worldwide. The aim of this review is to highlight the most recent studies regarding ovarian cancer pathogenesis and the new therapeutic approaches against this insidious disease. We focus on the relevance of some cell cycle genes, transcription factors, and microRNAs in the carcinogenesis of ovarian cancer as well as on a new hypothesis for therapy using histone deacetylase inhibitors. We also report recent studies regarding some mechanisms of chemoresistance, a major obstacle in the treatment of ovarian cancer. Together these studies can improve our knowledge of ovarian cancer tumorigenesis and diagnosis providing new tools to hopefully defeat this deadly disease.

A review of cost-effectiveness studies in ovarian cancer

BACKGROUND

Ovarian cancer is the fifth leading cause of all cancer-related deaths among women. While the costs of diagnosis and treatment impact the affected individual and the health system, the most important costs for the patient are often the pain and suffering associated with ovarian cancer. The quality of life associated with any management decision should be closely examined. Cost-effectiveness models take into account costs, effects, and quality of life and provide clinicians with useful tools to aid in making these difficult decisions.

METHODS

A comprehensive review of cost-effectiveness analyses was undertaken concerning screening for and treatment of ovarian cancer.

RESULTS

Screening methods to detect ovarian cancer are unproven, and the majority of women present with advanced-stage disease. Multimodal screening strategies with high specificities targeted at the highest-risk individuals are the most likely strategies to be cost-effective. Primary treatment with intravenous paclitaxel and platinum regimens has proven to be cost-effective in multiple studies. Studies evaluating intraperitoneal chemotherapy show that this strategy is potentially cost-effective over a long-term time horizon. A cost-effectiveness analysis of the management of recurrent platinum-sensitive ovarian cancer showed that treatment with carboplatin and paclitaxel is cost-effective compared to single-agent therapy. However, the preferred option for patients with recurrent platinum-resistant ovarian cancer appears to be supportive care (no chemotherapy) or single-agent therapy.

CONCLUSIONS

Many therapeutic choices are cost-effective in the treatment of ovarian cancer. Cost-effectiveness models offer one way to examine options in the management of a disease. The quality of life of the patient should be the most important factor in any management decision and is incorporated into well-designed studies on cost-effectiveness.

Comparative effectiveness of screening and prevention strategies among BRCA1/2-affected mutation carriers

Comparative effectiveness research has become an integral part of health care planning in most developed countries. In a simulated cohort of women, aged 30-65, who tested positive for BRCA1 or BRCA2 mutations, we compared outcomes of mammography with and without MRI, prophylactic oophorectomy with and without mastectomy, mastectomy alone, and chemoprevention.

METHODS

Using Treeage 9.02 software, we developed Markov models with 25,000 Monte Carlo simulations and conducted probabilistic sensitivity analysis. We based mutation penetrance rates, breast and ovarian cancer incidence, and mortality rates, and costs in terms of 2009 dollars, on published studies and data from the Surveillance, Epidemiology, and End RESULTS (SEER) Program and the Centers for Medicare and Medicaid Services. We used preference ratings obtained from mutation carriers and controls to adjust survival for quality of life (QALYs).

RESULTS

For BRCA1 mutation carriers, prophylactic oophorectomy at $1,741 per QALY, was more cost effective than both surgeries and dominated all other interventions. For BRCA2 carriers, prophylactic oophorectomy, at $4,587 per QALY, was more cost effective than both surgeries. Without quality adjustment, both mastectomy and BSO surgeries dominated all other interventions. In all simulations, preventive surgeries or chemoprevention dominated or were more cost effective than screening because screening modalities were costly.

CONCLUSION

Our analysis suggested that among BRCA1/2 mutation carriers, prophylactic surgery would dominate or be cost effective compared to chemoprevention and screening. Annual screening with MRI and mammography was the most effective strategy because it was associated with the longest quality-adjusted survival, but it was also very expensive.

Intraperitoneal chemotherapy for advanced epithelial ovarian malignancy: lessons learned

BACKGROUND

The administration of intraperitoneal (IP) chemotherapy as first-line adjuvant treatment for women with optimally debulked advanced ovarian malignancy results in improved median and overall survival when compared with intravenous (IV) chemotherapy. However, the number of adverse events and toxicities are increased in patients treated with IP chemotherapy. In addition, the administration of IP chemotherapy is technically more challenging and the schedule is more demanding in terms of time and resources.

AIMS

We report on our initial experience with the administration of IP chemotherapy at two gynaecological oncology units in Australia.

METHODS

We collected retrospective data from a series of 23 women undergoing IP chemotherapy as adjuvant treatment for advanced ovarian cancer. In addition to standard (Common Terminology Criteria for Adverse Events v3.0, CTCAE) toxicity data, we collected technical data specific to the administration of IP chemotherapy.

RESULTS

The average number of IP chemotherapy cycles received was 4.3. Forty-three per cent of patients received all six planned IP chemotherapy cycles. Thirty-nine per cent of patients discontinued their IP treatment. Of those, 22% were discontinued because of drug-related toxicities and the remaining 17% experienced a port complication or toxicity directly related to the route of administration.

CONCLUSIONS

This study demonstrates the feasibility and practicality of and lessons learned from initial experiences with IP chemotherapy for ovarian cancer in Australia.

A review of the current evidence for maintenance therapy in ovarian cancer

OBJECTIVES

Ovarian cancer (OC) typically is diagnosed at advanced stages, in which the primary goal of therapy is to prolong progression-free survival (PFS) and overall survival (OS). In recent years, maintenance therapy has been tested for this purpose in advanced OC (AOC). Literature on maintenance therapy in AOC was systematically reviewed to assess current knowledge regarding the impact of this therapeutic approach.

METHODS

A MEDLINE search was performed 2/2009 for articles published 1/2001-1/2009 pertaining to OC maintenance therapy guidelines, patterns, and outcomes. A second search used keywords specific to maintenance and included primary studies published in the last 10 years. Of 406 sources identified, 36 primary studies and 16 review articles were included in this systematic review. A third search used the keyword "consolidation" to find maintenance articles not identified through other searches; of 48 additional sources, 13 primary studies and 6 reviews were included. A fourth search of non-MEDLINE-indexed sources yielded 14 additional relevant publications from the same time period.

RESULTS

Among practice guidelines identified, only the National Comprehensive Cancer Network (NCCN) 2008 guidelines provide recommendations regarding maintenance therapy, assigning it a category 2B recommendation. No studies were identified that reported current treatment patterns or economic outcomes in maintenance therapy; quality of life data were reported in one study. A variety of agents have been tested for maintenance, with paclitaxel the most commonly evaluated. The Southwest Oncology Group-Gynecologic Oncology Group 178 trial has found that 12 cycles of paclitaxel extend PFS (by 7 months) compared to 3 months paclitaxel, but could not adequately evaluate OS.

CONCLUSIONS

Maintenance therapy may improve clinical outcomes in AOC, but additional research is needed to demonstrate an OS advantage. Future studies should investigate the long-term clinical benefit of maintenance treatment and its impact on resource utilization and health-related quality of life.

Should the treatment of peritoneal carcinomatosis by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy still be regarded as a highly morbid procedure?: a systematic review of morbidity and mortality

BACKGROUND

: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been offered in many institutions worldwide since the 1990s. Despite its existence of more than 10 years, this treatment has received heavy criticism for its morbidity and mortality rates. This consequentially resulted in a lack of randomized trials being conducted and translates into a lack of the most reliable form of scientific evidence in clinical research, hence limiting its general acceptance.

OBJECTIVE

: To report the morbidity and mortality outcomes of CRS and HIPEC from all institutions performing this treatment as a prelude toward establishing the safety of this treatment for peritoneal carcinomatosis.

METHODS

: A systematic review of relevant studies before August 2008 was performed. Each study was appraised using a predetermined protocol. The quality of studies was assessed. The morbidity and mortality of the treatment were synthesized through a narrative review with full tabulation of results of all included studies.

CONCLUSIONS

: The morbidity and mortality outcomes of CRS and HIPEC are similar to a major gastrointestinal surgery, such as a Whipple's procedure. To derive the maximal benefit of this treatment, careful patient selection with an optimal level of postoperative care must be advocated to avoid undesirable complications of this treatment.

Evaluation of an intraperitoneal chemotherapy program implemented at the Princess Margaret Hospital for patients with epithelial ovarian carcinoma

OBJECTIVE

A prospective evaluation of an ambulatory intraperitoneal (IP) /intravenous (IV) chemotherapy regimen for women with epithelial ovarian carcinoma (EOC).

METHODS

Cisplatin 100 mg/m(2) (option for 75 mg/m(2)) IP combined with paclitaxel 175 mg/m(2) IV (3 h infusion) administered every 21 days was adopted by our institution as a single day, outpatient regimen for women with stage III EOC who had undergone optimal cytoreductive (<or=1 cm) surgery. A prospective database including patient characteristics, toxicity (graded as per CTCAE-v 3.0) and time spent in the outpatient unit was established to follow patients receiving IP chemotherapy.

RESULTS

Between December 2005 and June 2008, 47 patients, median age 50 years (range 25-75) received a total of 238 cycles of IP/IV chemotherapy. The median number of cycles was 6 (range 1-6). 81% of patients (n=33) completed 6 planned cycles of treatment. Seven patients discontinued IP chemotherapy early due to catheter related complications (3) and chemotherapy toxicity (4). The most common grade 3 adverse events were abdominal pain (15%), nausea (15%), vomiting (13%), fatigue (11%) and peripherally neuropathy (9%). Residual peripheral neuropathy was reported at last follow up in 11 patients (grade 3 in 2). The median time spent in the chemotherapy unit was 7 h (range 6.5 to 9) per cycle.

CONCLUSIONS

Cisplatin 100 mg/m(2) IP combined with paclitaxel 175 mg/m(2) IV every 21 days is well tolerated and can be administered in an ambulatory chemotherapy unit. This regimen is convenient for patients and potentially more cost effective than other published IP cisplatin-based regimens.

Cost effectiveness of intraperitoneal compared with intravenous chemotherapy for women with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study

PURPOSE

To determine the cost effectiveness of intraperitoneal versus intravenous regimens for adjuvant treatment of optimally resected stage III ovarian cancer.

PATIENTS AND METHODS

A decision model was developed to compare the cost effectiveness at 7-, 11.5-, and 35-year horizons of intravenous carboplatin and paclitaxel (IV-CARBO/PAC), intravenous cisplatin and paclitaxel (IV-CIS/PAC), or intravenous paclitaxel followed by intraperitoneal cisplatin and paclitaxel (IP-CIS/PAC). Survival data were from women participating in representative Gynecologic Oncology Group (GOG) protocols. Medicare reimbursement rates and the Agency for Healthcare Research and Quality Database were used to estimate costs for treatment regimens and grade 3 to 4 adverse effects, respectively.

RESULTS

Median predicted survival was 66, 57, 51, and 48 months for IP-CIS/PAC, IV-CARBO/PAC, IV-CIS/PAC (GOG 172), or IV-CIS/PAC (GOG 158), respectively. Across a range of analyses, IV-CIS/PAC was more costly and had lower life expectancy than IV-CARBO/PAC. Compared with IV-CARBO/PAC, IP-CIS/PAC had an incremental cost-effectiveness ratio (ICER) of $180,022 per quality-adjusted life year (QALY) saved at a 7-year time horizon, $71,835/QALY at 11.5 years, and $32,053/QALY over a lifetime. Extending the survival advantage of IP-CIS/PAC over 11.5 years and a lifetime results in ICERs of $26,249 and $23,973, respectively. Assuming IP-CIS/PAC and IV-CIS/PAC were equally effective when administered on an outpatient basis, the ICER of IP-CIS/PAC compared with IV-CARBO/PAC was $26,311.

CONCLUSION

Inpatient IP-CIS/PAC, while not cost effective compared with IV-CARBO/PAC at 7 years, becomes cost effective if a longer time horizon is modeled and/or a survival benefit can be assumed to persist longer than currently available data. Outpatient IP-CIS/PAC may also be cost effective compared with IV-CARBO/PAC if proven as effective as inpatient IP-CIS/PAC.