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Allanson E, Hari A, Ndaboine E, Cohen PA, Bristow R. Medicolegal, infrastructural, and financial aspects in gynecologic cancer surgery and their implications in decision making processes: Quo Vadis? Int J Gynecol Cancer 2024; 34:451-458. [PMID: 38438180 DOI: 10.1136/ijgc-2023-004585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Surgical decision making is complex and involves a combination of analytic, intuitive, and cognitive processes. Medicolegal, infrastructural, and financial factors may influence these processes depending on the context and setting, but to what extent can they influence surgical decision making in gynecologic oncology? This scoping review evaluates existing literature related to medicolegal, infrastructural, and financial aspects of gynecologic cancer surgery and their implications in surgical decision making. Our objective was to summarize the findings and limitations of published research, identify gaps in the literature, and make recommendations for future research to inform policy.
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Affiliation(s)
- Emma Allanson
- Division of Obstetrics and Gynaecology, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Anjali Hari
- Division of Gynecologic Oncology, University of California Irvine, Orange, California, USA
| | - Edgard Ndaboine
- Department of Obstetrics & Gynecology, Catholic University of Health and Allied Sciences, Mwanza, Mwanza, Tanzania
| | - Paul A Cohen
- Division of Obstetrics and Gynaecology, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Robert Bristow
- Division of Gynecologic Oncology, University of California Irvine, Orange, California, USA
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Orellana TJ, Kim H, Beriwal S, Taylor SE, Smith KJ, Lesnock JL. Cost-effectiveness analysis of tumor molecular testing in stage III endometrial cancer. Gynecol Oncol 2023; 173:81-87. [PMID: 37105061 PMCID: PMC11225569 DOI: 10.1016/j.ygyno.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/10/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Standard of care for adjuvant treatment of stage III endometrial cancer includes chemotherapy and radiation. In addition to stage, tumor molecular profiles may predict treatment outcomes, and prospective clinical trials are ongoing. However, tumor molecular testing is costly and time-consuming. Our objective was to evaluate the cost-effectiveness of tumor molecular testing in stage III endometrial cancer. METHODS A Markov decision model compared two strategies for stage III endometrial cancer: Tumor Molecular Testing (TMT) versus No TMT. TMT included sequential POLE next generation sequencing, mismatch repair immunohistochemistry (IHC), and p53 IHC. POLE-mutated patients were assigned to adjuvant radiation therapy; all others including controls were assigned to adjuvant chemoradiation. First recurrences were treated with 6 cycles of carboplatin and paclitaxel. Second recurrences were treated with pembrolizumab alone for mismatch repair deficient patients and both pembrolizumab and lenvatinib for other patients. Sensitivity analyses were performed to test model robustness. RESULTS Compared to No TMT, TMT was cost saving with equivalent effectiveness. On one-way sensitivity analysis, TMT remained cost saving over all parameter ranges. TMT was also favored on probabilistic sensitivity analysis in 80% of iterations at a willingness-to-pay threshold of $100,000/quality adjusted life-year (QALY) gained. However, when TMT was compared to mismatch repair IHC alone, TMT cost $182,798/QALY gained. CONCLUSIONS In this model of patients with stage III endometrial cancer, TMT was cost saving compared to No TMT. However, when compared to mismatch repair IHC alone, TMT was economically unfavorable.
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Affiliation(s)
- Taylor J Orellana
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA, 15213, United States.
| | - Hayeon Kim
- Department of Radiation Oncology, University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, 5115 Centre Avenue, Pittsburgh, PA 15232, United States
| | - Sushil Beriwal
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, United States; Varian Medical Systems, Palo Alto, CA, United States
| | - Sarah E Taylor
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA, 15213, United States
| | - Kenneth J Smith
- Center for Research on Health Care, Department of Medicine, University of Pittsburgh School of Medicine, 200 Meyran Ave., Suite 200, Pittsburgh, PA 15213, United States
| | - Jamie L Lesnock
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA, 15213, United States
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Huang D, Harrison R, Curtis E, Mirabadi N, Chen GY, Alexandridis R, Barroilhet L, Rose S, Hartenbach E, Al-Niami A. Beyond post-operative readmissions: analysis of the impact of unplanned readmissions during primary treatment of advanced-stage epithelial ovarian cancer on long-term oncology outcome. Int J Gynecol Cancer 2023; 33:741-748. [PMID: 36808044 DOI: 10.1136/ijgc-2022-003765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Multiple studies have assessed post-operative readmissions in advanced ovarian cancer. OBJECTIVE To evaluate all unplanned readmissions during the primary treatment period of advanced epithelial ovarian cancer, and the impact of readmission on progression-free survival. METHODS This was a single institution retrospective study from January 2008 to October 2018. Χ2/Fisher's exact and t-test, or Kruskal-Wallis test were used. Multivariable Cox proportional hazard models were used to assess the effect of covariates in progression-free survival analysis. RESULTS A total of 484 patients (279 primary cytoreductive surgery, 205 neoadjuvant chemotherapy) were analyzed. In total, 272 of 484 (56%; 37% primary cytoreductive surgery, 32% neoadjuvant chemotherapy, p=0.29) patients were readmitted during the primary treatment period. Overall, 42.3% of the readmissions were surgery related, 47.8% were chemotherapy related, and 59.6% were cancer related but not related to surgery or chemotherapy, and each readmission could qualify for more than one reason. Readmitted patients had a higher rate of chronic kidney disease (4.1% vs 1.0%, p=0.038). Post-operative, chemotherapy, and cancer-related readmissions were similar between the two groups. However, the percentage of inpatient treatment days due to unplanned readmission was twice as high for primary cytoreductive surgery at 2.2% vs 1.3% for neoadjuvant chemotherapy (p<0.001). Despite longer readmissions in the primary cytoreductive surgery group, Cox regression analysis demonstrated that readmissions did not affect progression-free survival (HR=1.22, 95% CI 0.98 to 1.51; p=0.08). Primary cytoreductive surgery, higher modified Frailty Index, grade 3 disease, and optimal cytoreduction were associated with longer progression-free survival. CONCLUSIONS In this study, 35% of the women with advanced ovarian cancer had at least one unplanned readmission during the entire treatment time. Patients treated by primary cytoreductive surgery spent more days during readmission than those with neoadjuvant chemotherapy. Readmissions did not affect progression-free survival and may not be valuable as a quality metric.
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Affiliation(s)
- Dandi Huang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA .,Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ross Harrison
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Erin Curtis
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Nina Mirabadi
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Department of General Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Grace Yi Chen
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Roxana Alexandridis
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lisa Barroilhet
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Stephen Rose
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ellen Hartenbach
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ahmed Al-Niami
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Orellana TJ, Kim H, Beriwal S, Bhargava R, Berger J, Buckanovich RJ, Coffman LG, Courtney-Brooks M, Mahdi H, Olawaiye AB, Sukumvanich P, Taylor SE, Smith KJ, Lesnock JL. Cost-effectiveness analysis of tumor molecular classification in high-risk early-stage endometrial cancer. Gynecol Oncol 2021; 164:129-135. [PMID: 34740462 DOI: 10.1016/j.ygyno.2021.10.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/04/2021] [Accepted: 10/10/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Tumor molecular analyses in endometrial cancer (EC) includes 4 distinct subtypes: (1) POLE-mutated, (2) mismatch repair protein (MMR) deficient, (3) p53 mutant, and (4) no specific molecular profile. Recently, a sub-analysis of PORTEC-3 demonstrated notable differences in treatment response between molecular classification (MC) groups. Cost of testing is one barrier to widespread adoption of MC. Therefore, we sought to determine the cost-effectiveness of MC in patients with stage I and II high-risk EC. METHODS A Markov decision model was developed to compare tumor molecular classification (TMC) vs. no testing (NT). A healthcare payor's perspective and 5-year time horizon were used. Base case data were abstracted from PORTEC-3 and the molecular sub-analysis. Cost and utility data were derived from public databases, peer-reviewed literature, and expert input. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with effectiveness in quality-adjusted life years (QALYs) and evaluated with a willingness-to-pay threshold of $100,000 per QALY gained. Sensitivity analyses were performed to test model robustness. RESULTS When compared to NT, TMC was cost effective with an ICER of $25,578 per QALY gained; incremental cost was $1780 and incremental effectiveness was 0.070 QALYs. In one-way sensitivity analyses, results were most sensitive to the cost of POLE testing, but TMC remained cost-effective over all parameter ranges. CONCLUSIONS TMC in early-stage high-risk EC is cost-effective, and the model results were robust over a range of parameters. Given that MC can be used to guide adjuvant treatment decisions, these findings support adoption of TMC into routine practice.
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Affiliation(s)
- T J Orellana
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA 15213, United States.
| | - H Kim
- Department of Radiation Oncology, University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, 5115 Centre Avenue, Pittsburgh, PA 15232, United States
| | - S Beriwal
- Department of Radiation Oncology, University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, 5115 Centre Avenue, Pittsburgh, PA 15232, United States
| | - R Bhargava
- Department of Pathology, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA 15213, United States
| | - J Berger
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA 15213, United States
| | - R J Buckanovich
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA 15213, United States; Division of Hematology/Oncology, Department of Medicine, Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, United States
| | - L G Coffman
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA 15213, United States; Division of Hematology/Oncology, Department of Medicine, Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, United States
| | - M Courtney-Brooks
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA 15213, United States
| | - H Mahdi
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA 15213, United States
| | - A B Olawaiye
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA 15213, United States
| | - P Sukumvanich
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA 15213, United States
| | - S E Taylor
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA 15213, United States
| | - K J Smith
- Center for Research on Health Care, Department of Medicine, University of Pittsburgh School of Medicine, 200 Meyran Ave., Suite 200, Pittsburgh, PA 15213, United States
| | - J L Lesnock
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens' Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1750, Pittsburgh, PA 15213, United States
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Craig AD, Garcia E, Peters PN, Chen LM, Chapman JS. Primary treatment of advanced ovarian cancer: how does the 'real world' practice? Future Oncol 2021; 17:4687-4696. [PMID: 34435878 DOI: 10.2217/fon-2021-0086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Aims: This study evaluated primary treatment modalities in advanced ovarian cancer according to sociodemographic characteristics and characterized chemotherapy regimens used. Methods: This was a retrospective study of newly diagnosed advanced ovarian, tubal or peritoneal cancer patients at two hospitals from 2011 to 2016. Results: Of 175 women, 41% received neoadjuvant chemotherapy and 59% received primary cytoreductive surgery. Within the neoadjuvant chemotherapy group, 23% did not have a surgical consultation prior to initiating treatment. Women receiving neoadjuvant chemotherapy lived closer to an academic center and more frequently received carboplatin/paclitaxel every 3 weeks. Cytoreductive surgery patients more frequently received intraperitoneal chemotherapy. Conclusion: The authors identified disparities in age, insurance, distance from treatment center and chemotherapy choice in the primary treatment for ovarian cancer.
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Affiliation(s)
- Amaranta D Craig
- Division of Gynecologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Eduardo Garcia
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Pamela N Peters
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Lee-May Chen
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco; San Francisco, CA 94158, USA
| | - Jocelyn S Chapman
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco; San Francisco, CA 94158, USA
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Coleridge SL, Bryant A, Kehoe S, Morrison J. Neoadjuvant chemotherapy before surgery versus surgery followed by chemotherapy for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2021; 7:CD005343. [PMID: 34328210 PMCID: PMC8406953 DOI: 10.1002/14651858.cd005343.pub6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require a combination of surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases up to 9 October 2020: the Cochrane Central Register of Controlled Trials (CENTRAL), Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. We extracted data of overall (OS) and progression-free survival (PFS), adverse events, surgically-related mortality and morbidity and quality of life outcomes. We used GRADE methods to determine the certainty of evidence. MAIN RESULTS We identified 2227 titles and abstracts through our searches, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1774 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the four studies where data were available and found little or no difference with regard to overall survival (OS) (Hazard Ratio (HR) 0.96, 95% CI 0.86 to 1.08; participants = 1692; studies = 4; high-certainty evidence) or progression-free survival in four trials where we were able to pool data (Hazard Ratio 0.98, 95% CI 0.88 to 1.08; participants = 1692; studies = 4; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were variably and incompletely reported across studies. There are probably clinically meaningful differences in favour of NACT compared to PDS with regard to overall postoperative serious adverse effects (SAE grade 3+): 6% in NACT group, versus 29% in PDS group, (risk ratio (RR) 0.22, 95% CI 0.13 to 0.38; participants = 435; studies = 2; heterogeneity index (I2) = 0%; moderate-certainty evidence). NACT probably results in a large reduction in the need for stoma formation: 5.9% in NACT group, versus 20.4% in PDS group, (RR 0.29, 95% CI 0.12 to 0.74; participants = 632; studies = 2; I2 = 70%; moderate-certainty evidence), and probably reduces the risk of needing bowel resection at the time of surgery: 13.0% in NACT group versus 26.6% in PDS group (RR 0.49, 95% CI 0.30 to 0.79; participants = 1565; studies = 4; I2 = 79%; moderate-certainty evidence). NACT reduces postoperative mortality: 0.6% in NACT group, versus 3.6% in PDS group, (RR 0.16, 95% CI 0.06 to 0.46; participants = 1623; studies = 5; I2 = 0%; high-certainty evidence). QoL on the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) scale produced inconsistent and imprecise results in three studies (MD -0.29, 95% CI -2.77 to 2.20; participants = 524; studies = 3; I2 = 81%; very low-certainty evidence) but the evidence is very uncertain and should be interpreted with caution. AUTHORS' CONCLUSIONS The available high to moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT probably reduces the risk of serious adverse events, especially those around the time of surgery, and reduces the risk of postoperative mortality and the need for stoma formation. These data will inform women and clinicians (involving specialist gynaecological multidisciplinary teams) and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Sean Kehoe
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, Musgrove Park Hospital, Taunton, UK
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Wu D, Li J, Wang Y, Huang H, Huang C. Cost-effectiveness analysis of neoadjuvant versus adjuvant chemotherapy for cT2-4N0-1 non-small cell lung cancer patients during initial treatment phase. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:44. [PMID: 34281538 PMCID: PMC8287679 DOI: 10.1186/s12962-021-00280-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/28/2021] [Indexed: 12/09/2022] Open
Abstract
Objective The choice between neoadjuvant chemotherapy (NAC) and adjuvant chemotherapy (AC) remains controversial in the treatment of non-small cell lung cancer (NSCLC). There is no significant difference in NAC and AC’s effectiveness. We investigate the cost-effectiveness of NAC versus AC for NSCLC. Method A decision tree model was designed from a payer perspective to compare NAC and AC treatments for NSCLC patients. Parameters included overall survival (OS), surgical complications, chemotherapy adverse events (AEs), treatment initiation probability, treatment time frame, treatment cost, and quality of life (QOL). Sensitivity analyses were performed to characterize model uncertainty in the base cases. Result AC treatment strategy produced a cost saving of ¥3064.90 and incremental quality-adjusted life-years (QALY) of 0.10 years per patient with the same OS. NAC would be cost-effective at a ¥35,446/QALY threshold if the median OS of NAC were 2.3 months more than AC. The model was robust enough to handle variations to all input parameters except OS. In the probability sensitivity analysis, AC remained dominant in 54.4% of simulations. Conclusion The model cost-effectiveness analysis indicates that with operable NSCLC, AC treatment is more cost-effective to NAC. If NAC provides a longer survival advantage, this treatment strategy may be cost-effective. The OS is the main factor that influences cost-effectiveness and should be considered in therapeutic regimes. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-021-00280-w.
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Affiliation(s)
- Dongdong Wu
- Department of Information, Daping Hospital, Army Medical University, Chongqing, China
| | - Juan Li
- Department of Oncology, Daping Hospital, Army Medical University, Chongqing, China
| | - Yubo Wang
- Respiratory Department, Daping Hospital, Army Medical University, Chongqing, China
| | - Hao Huang
- Department of Information, Daping Hospital, Army Medical University, Chongqing, China
| | - Chunji Huang
- Army Medical University, Gaotan Rock, Shapingba District, Chongqing, 400038, China.
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Coleridge SL, Bryant A, Kehoe S, Morrison J. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2021; 2:CD005343. [PMID: 33543776 PMCID: PMC8094177 DOI: 10.1002/14651858.cd005343.pub5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases on 11 February 2019: CENTRAL, Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. MAIN RESULTS We found 1952 potential titles, with a most recent search date of February 2019, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1713 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the three studies where data were available and found little or no difference with regard to overall survival (OS) (1521 women; Hazard Ratio (HR) 0.95, 95% CI 0.84 to 1.07; I2 = 0%; moderate-certainty evidence) or progression-free survival in four trials where we were able to pool data (1631 women; HR 0.97, 95% CI 0.87 to 1.07; I2 = 0%; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were poorly and incompletely reported across studies. There may be clinically meaningful differences in favour of NACT compared to PDS with regard to serious adverse effects (SAE grade 3+). These data suggest that NACT may reduce the risk of need for blood transfusion (risk ratio (RR) 0.80; 95% CI 0.64 to 0.99; four studies,1085 women; low-certainty evidence), venous thromboembolism (RR 0.28; 95% CI 0.09 to 0.90; four studies, 1490 women; low-certainty evidence), infection (RR 0.30; 95% CI 0.16 to 0.56; four studies, 1490 women; moderate-certainty evidence), compared to PDS. NACT probably reduces the need for stoma formation (RR 0.43, 95% CI 0.26 to 0.72; two studies, 581 women; moderate-certainty evidence) and bowel resection (RR 0.49, 95% CI 0.26 to 0.92; three studies, 1213 women; moderate-certainty evidence), as well as reducing postoperative mortality (RR 0.18; 95% CI 0.06 to 0.54:five studies, 1571 women; moderate-certainty evidence). QoL on the EORTC QLQ-C30 scale produced inconsistent and imprecise results in two studies (MD -1.34, 95% CI -2.36 to -0.32; participants = 307; very low-certainty evidence) and use of the QLQC-30 and QLQC-Ov28 in another study (MD 7.60, 95% CI 1.89 to 13.31; participants = 217; very low-certainty evidence) meant that little could be inferred. AUTHORS' CONCLUSIONS The available moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT may reduce the risk of serious adverse events, especially those around the time of surgery, and the need for bowel resection and stoma formation. These data will inform women and clinicians and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Obstetrics and Gynaecology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Sean Kehoe
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, Musgrove Park Hospital, Taunton, UK
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Nica A, Lee JYJ, Hong NL, May T. Cost-effectiveness of maintenance hormonal therapy in patients with advanced low grade serous ovarian cancer. Gynecol Oncol 2020; 160:206-213. [PMID: 33032821 DOI: 10.1016/j.ygyno.2020.09.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/28/2020] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To assess the cost-effectiveness of using maintenance hormonal therapy in patients with low grade serous ovarian cancer (LGSC). METHODS A simulated decision analysis with a Markov decision model over a lifetime horizon was performed using the base case of a 47-year old patient with stage IIIC, LGSC following first-line treatment with primary cytoreductive surgery and adjuvant chemotherapy. Two treatment strategies were analyzed - maintenance daily letrozole until disease progression and routine observation. The analysis was from the perspective of the healthcare payer. Direct medical costs were estimated using public data sources and previous literature and were reported in adjusted 2018 Canadian dollars. The model estimated lifetime cost, quality-adjusted life years (QALY), life years (LY), median overall survival (OS), and number of recurrences with each strategy. Cost-effectiveness was compared using an incremental cost-effectiveness ratio (ICER). A strategy was considered cost-effective when the ICER was less than the willingness to pay (WTP) threshold of $50,000 CAD per QALY. Deterministic sensitivity analysis was performed to assess the impact of changing key clinical and cost variables. RESULTS Maintenance letrozole was the preferred strategy with an associated lifetime cost of $69,985 CAD ($52,620 USD) and an observed improvement of 0.91 QALYs and 1.55 LYs. The ICER for letrozole maintenance therapy was an additional $11,037 CAD ($8298 USD) per QALY. The modeled median OS was 150 months with maintenance letrozole and 126 months in the observation strategy. The maintenance letrozole strategy resulted in 34% and 17% fewer first recurrences at 5-year and 10-year follow-up, respectively. CONCLUSION Maintenance letrozole is a cost-effective treatment strategy in patients with advanced LGSC resulting in clinically-relevant improvement in QALYs, LYs, and fewer disease recurrences.
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Affiliation(s)
- Andra Nica
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Toronto, ON, Canada
| | | | - Nicole Look Hong
- Department of Surgical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Taymaa May
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Toronto, Toronto, ON, Canada; Division of Gynecologic Oncology, Department of Surgical Oncology, Princess Margaret Cancer Center, Toronto, ON, Canada.
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Koirala P, Moon AS, Chuang L. Clinical Utility of Preoperative Assessment in Ovarian Cancer Cytoreduction. Diagnostics (Basel) 2020; 10:E568. [PMID: 32784719 PMCID: PMC7459574 DOI: 10.3390/diagnostics10080568] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/01/2020] [Accepted: 08/02/2020] [Indexed: 01/04/2023] Open
Abstract
Ovarian cancer is the deadliest gynecologic cancer, in part due to late presentation. Many women have vague early symptoms and present with disseminated disease. Cytoreductive surgery can be extensive, involving multiple organ systems. Novel therapies and recent clinical trials have provided evidence that, compared to primary cytoreduction, neoadjuvant chemotherapy has equivalent survival outcomes with less morbidity. There is increasing need for validated tools and mechanisms for clinicians to determine the optimal management of ovarian cancer patients.
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Affiliation(s)
- Pratistha Koirala
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Danbury Hospital, Danbury, CT 06810, USA; (A.S.M.); (L.C.)
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Coleridge SL, Bryant A, Lyons TJ, Goodall RJ, Kehoe S, Morrison J. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2019; 2019:CD005343. [PMID: 31684686 PMCID: PMC6822157 DOI: 10.1002/14651858.cd005343.pub4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases on 11 February 2019: CENTRAL, Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. MAIN RESULTS We found 1952 potential titles, with a most recent search date of February 2019, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1713 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the three studies where data were available and found little or no difference with regard to overall survival (OS) (1521 women; hazard ratio (HR) 1.06; 95% confidence interval (CI) 0.94 to 1.19, I2 = 0%; moderate-certainty evidence) or progression-free survival in four trials where we were able to pool data (1631 women; HR 1.02; 95% CI 0.92 to 1.13, I2 = 0%; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were poorly and incompletely reported across studies. There may be clinically meaningful differences in favour of NACT compared to PDS with regard to serious adverse effects (SAE grade 3+). These data suggest that NACT may reduce the risk of need for blood transfusion (risk ratio (RR) 0.80; 95% CI 0.64 to 0.99; four studies,1085 women; low-certainty evidence), venous thromboembolism (RR 0.28; 95% CI 0.09 to 0.90; four studies, 1490 women; low-certainty evidence), infection (RR 0.30; 95% CI 0.16 to 0.56; four studies, 1490 women; moderate-certainty evidence), compared to PDS. NACT probably reduces the need for stoma formation (RR 0.43, 95% CI 0.26 to 0.72; two studies, 581 women; moderate-certainty evidence) and bowel resection (RR 0.49, 95% CI 0.26 to 0.92; three studies, 1213 women; moderate-certainty evidence), as well as reducing postoperative mortality (RR 0.18; 95% CI 0.06 to 0.54:five studies, 1571 women; moderate-certainty evidence). QoL on the EORTC QLQ-C30 scale produced inconsistent and imprecise results in two studies (MD -1.34, 95% CI -2.36 to -0.32; participants = 307; very low-certainty evidence) and use of the QLQC-30 and QLQC-Ov28 in another study (MD 7.60, 95% CI 1.89 to 13.31; participants = 217; very low-certainty evidence) meant that little could be inferred. AUTHORS' CONCLUSIONS The available moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT may reduce the risk of serious adverse events, especially those around the time of surgery, and the need for bowel resection and stoma formation. These data will inform women and clinicians and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Taunton and Somerset NHS Foundation TrustObstetrics and GynaecologyMusgrove Park HospitalTauntonUKTA1 5DA
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Thomas J Lyons
- University of BristolSchool of Medical Sciences38 Kings Parade AvenueBristolUKBS8 2RB
| | - Richard J Goodall
- Imperial College LondonDepartment of Surgery and CancerKensingtonLondonUKSW7 2AZ
| | - Sean Kehoe
- University of BirminghamInstitute of Cancer and GenomicsBirminghamUKB15 2TT
| | - Jo Morrison
- Musgrove Park HospitalDepartment of Gynaecological OncologyTaunton and Somerset NHS Foundation TrustTauntonSomersetUKTA1 5DA
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Horner W, Peng K, Pleasant V, Brackmann M, Ebott J, Gutfreund R, McLean K, Reynolds RK, Uppal S. Trends in surgical complexity and treatment modalities utilized in the management of ovarian cancer in an era of neoadjuvant chemotherapy. Gynecol Oncol 2019; 154:283-289. [PMID: 31196575 DOI: 10.1016/j.ygyno.2019.05.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To investigate the impact of the increased use of neoadjuvant chemotherapy on the complexity of cytoreductive surgeries for ovarian cancer. METHODS Using the National Cancer Database, we performed a retrospective cohort study of women diagnosed between 2004 and 2015 with stage III or IV epithelial ovarian cancer who underwent either primary cytoreductive surgery (PDS) followed by adjuvant chemotherapy, neoadjuvant chemotherapy (NACT) followed by interval debulking surgery. Cases were assigned a surgical complexity category as 1) Inadequate, 2) Low, 3) Moderate and, 4) High complexity. The primary outcome was the trend in surgical complexity over time. Secondary outcomes included temporal trends in treatment modality, perioperative mortality, and survival. RESULTS At total of 52,582 (76.3%) underwent PDS and 16,307 (23.7%) underwent NACT. The utilization of NACT increased from 7.7% in 2004 to 27.8% in 2015 (p-trend < 0.001). Patients undergoing moderate complexity surgeries increased from 28.9% to 33.5% and high complexity surgeries from 26.3% to 30% (p-trend < 0.001, for both). Trends in increasing surgical complexity were seen in both NACT and PDS cohorts. This increase in surgical complexity was seen most profoundly at the high-volume centers. Overall 30-day mortality decreased from 3.4% in 2004 to 1.4% in 2015; and 90-day mortality decreased from 7.6% to 4%. During the same time, 5-year survival increased from 39.7% to 49%. CONCLUSIONS Increase in the utilization of NACT is associated with decreased 30- and 90-day mortality and increase in five-year survival. Moreover, the overall complexity of ovarian cancer surgery has increased in both PDS and NACT cohorts.
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Affiliation(s)
- Whitney Horner
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, United States of America
| | - Katherine Peng
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, United States of America
| | - Versha Pleasant
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, United States of America
| | - Melissa Brackmann
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, United States of America
| | - Jasmine Ebott
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, United States of America
| | - Rachel Gutfreund
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, United States of America
| | - Karen McLean
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, United States of America
| | - R Kevin Reynolds
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, United States of America
| | - Shitanshu Uppal
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Michigan, Ann Arbor, MI, United States of America.
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Neoadjuvant chemotherapy before definite operative approach for women with advanced-stage epithelial ovarian cancer. Taiwan J Obstet Gynecol 2019; 57:623-624. [PMID: 30342639 DOI: 10.1016/j.tjog.2018.08.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2018] [Indexed: 02/07/2023] Open
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