Anticoagulant Therapy for Cancer-Associated Thrombosis : A Cost-Effectiveness Analysis

Cost-effectiveness Analysis of Tumor Treating Fields Therapy Combined With Immune Checkpoint Inhibitor in Metastatic Non-small-cell Lung Cancer

BACKGROUND

The LUNAR clinical trial revealed that incorporating Tumor Treating Fields (TTFields) therapy alongside immune checkpoint inhibitor (ICI) significantly prolonged the overall survival of patients with metastatic, platinum-resistant non-small-cell lung cancer (NSCLC). However, the cost of TTFields therapy is high and may further increase the financial burden for patients. Our research aims to evaluate the cost-effectiveness of TTFields therapy addition with ICI for metastatic NSCLC.

METHODS

We constructed a Markov model to evaluate the healthcare costs associated with TTFields therapy combined with ICI for the treatment of advanced NSCLC. In this model, the clinical data utilized came from the LUNAR trial, while drug costs and health state utility values were extracted from public databases and relevant scholarly publications. The major outcomes incorporated costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER).

RESULTS

Compared with ICI therapy alone, ICI combination with TTFields therapy resulted in 0.42 QALYs at the cost of $167,329, with an ICER of $398,402.38 per year. The calculated ICER surpassed the generally accepted US willingness-to-pay (WTP) threshold of 150,000 per QALY. One-way sensitivity analyses demonstrated that the utility of progression disease is the most influential factor, followed by the cost of TTFields therapy, the utility of progression-free survival, the cost of ICI, and the cost of adverse events in TTFields therapy combined with ICI. Only when the cost of TTFields therapy is reduced by approximately 80.48%, it would be cost-effective within the commonly accepted WTP threshold of $150,000/QALY.

CONCLUSIONS

According to the US WTP, the combination of TTFields therapy with ICI does not currently represent a cost-effective strategy for metastatic NSCLC followed progression on platinum-resistant therapy. Considering its promising clinical outcomes for metastatic NSCLC, it is necessary to control the expenses of this therapeutic strategy in future applications.

Clinical Efficacy and Safety of Novel Anticoagulants for the Management of Venous Thromboembolism in Patients with Cancer: A Systematic Review and Meta-Analysis

PURPOSE

Cancer patients face a four- to sevenfold higher risk of venous thromboembolism (VTE) than the general population. Novel oral anticoagulants (NOACs) provide convenient alternatives to traditional therapies.

METHODS

We performed a systematic literature search across PubMed, Embase, and the Cochrane Library, targeting studies that examined the use of NOACs in cancer-associated VTE. The search included randomized controlled trials (RCTs). Selected studies compared NOACs with low-molecular-weight heparin (LMWH) or vitamin K antagonists (VKA) in cancer patients diagnosed with VTE. A meta-analysis using a random-effects model was applied to estimate pooled effect sizes for outcomes.

RESULTS

In this meta-analysis, we included 12 RCTs. Results showed NOACs were more effective than LMWH in preventing VTE recurrence (RR 0.66, 95% CI 0.52-0.83, p = 0.0004). Compared with VKAs, NOACs showed no significant difference (RR 0.63, 95% CI 0.34-1.15, p = 0.13). However, this finding is limited by the small patient sample. Major bleeding outcomes were similar between NOACs and LMWH/VKAs (RR 1.24, 95% CI 0.85-1.80, p = 0.28; RR 0.77, 95% CI 0.39-1.53, p = 0.46, respectively). Meta-regression analysis indicated a statistically significant positive correlation between mortality and major bleeding events when comparing NOACs with LMWH (p = 0.049). There was no significant difference in all-cause mortality between patients treated with NOACs and those treated with LMWH (RR 1.04, 95% CI 0.92-1.18, p = 0.54) or VKAs (RR 0.94, 95% CI 0.72-1.23, p = 0.65).

CONCLUSION

Meta-analysis shows NOACs, especially factor Xa inhibitors, reduce VTE recurrence in cancer patients more effectively than LMWH. Comparison between NOACs and VKAs is inconclusive due to limited patient data. Further research is needed to assess NOACs' efficacy and safety against VKAs.

Thromboprophylaxis in multiple myeloma: a case-based review with practical guidelines

Venous thromboembolism (VTE) poses a significant challenge in the context of multiple myeloma, with an incidence of up to 10% in newly diagnosed patients and varying frequency in the relapsed/refractory setting. Accurate VTE risk assessment and personalized thromboprophylaxis strategies are important parts of supportive care in myeloma. There are three validated risk assessment models for prediction of VTE risk in newly diagnosed myeloma-SAVED, IMPEDE-VTE, and PRISM. In this review, we delve into the practical applications of VTE risk prediction models in the context of current therapies. By emphasizing the necessity of a tailored approach, we underscore the importance of considering patient-specific, disease-specific, and treatment-specific risk factors in each clinical scenario, and using that data to complement the output from risk assessment models. We also provide a summary of currently available data on VTE thromboprophylaxis in myeloma, and highlight specific situations where direct oral anticoagulants should be strongly considered. Our objective is to fill the critical gaps in VTE prophylaxis and management through the analysis of specific patient cases and provide a practical overview for clinicians.

Comparison of direct oral anticoagulant (DOAC) versus low-molecular-weight heparin (LMWH) for venous thromboprophylaxis after radical cystectomy: A systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

Radical cystectomy in bladder cancer patients can result in postoperative complications, including venous thromboembolism (VTE), with an incidence reported between 3% and 11.6%. Although low-molecular-weight heparin (LMWH) is the recommended prophylactic treatment, challenges such as financial constraints and patient adherence remain. Direct Oral Anticoagulants (DOACs) present an alternative, but their comparative efficacy and safety against LMWHs in preventing VTE after radical cystectomy need further evaluation. This study aims to compare the efficacy and safety of LMWHs vs. DOACs for VTE prophylaxis following radical cystectomy.

MATERIALS AND METHODS

A systematic search was performed across 3 electronic databases to identify relevant studies utilizing DOACs and LMWHs for VTE prophylaxis after radical cystectomy. The primary outcomes of interest were VTE and bleeding events. Fixed-effect models were employed to summarize the outcomes, with results presented as odds ratios (OR) and their corresponding 95% confidence intervals (CI).

RESULTS

The analysis included a total of 541 patients from three studies. The pooled data indicated that patients on DOACs had a statistically nonsignificant lower odds of VTE (OR 0.41 [95% CI 0.13-1.36], P = 0.15) and a statistically nonsignificant higher odds of bleeding events (OR 3.03 [95% CI 0.53-17.23], P = 0.21).

CONCLUSIONS

Our findings suggest that DOACs are comparable to LMWHs in terms of VTE and bleeding events for thromboprophylaxis following radical cystectomy. The choice of prophylactic agent can be guided by patient preference and clinical judgment. However, additional randomized controlled trials with larger sample sizes are necessary to confirm these findings.

Effectiveness and safety of rivaroxaban or low-molecular-weight heparin in non-major orthopedic surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Patients undergoing non-major orthopedic surgery often face an increased risk of venous thromboembolism due to the necessity of immobilization postoperatively. Current guidelines commonly recommend the use of low-molecular-weight heparin (LMWH) for prophylaxis, but it is associated with low patient compliance and certain side effects. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the effectiveness and safety of rivaroxaban or LMWH for thromboprophylaxis following non-major orthopedic surgery.

METHOD

Relevant literature was systematically searched in PubMed, Web of Science, Cochrane Library, and Embase from their inception to October 1, 2023, to evaluate the effectiveness and safety of rivaroxaban or LMWH in RCTs for thromboprophylaxis following non-major orthopedic surgery.

RESULTS

A total of 5 randomized controlled trials involving 5,101 patients were included. There was no statistically significant difference in the preventive effect against venous thromboembolism (VTE) when using rivaroxaban or LMWH following non-major orthopedic surgery (RR 0.80; 95%CI 0.31 to 2.07). In terms of safety, there was also no statistically significant difference in the incidence of bleeding events in patients undergoing non-major orthopedic surgery when using rivaroxaban or LMWH (RR 1.15; 95% CI 0.75 to 1.76).

CONCLUSION

In non-major orthopedic surgery, the risk of venous thromboembolism and bleeding complications is similar when using rivaroxaban or LMWH.

Venous Thromboembolism Prophylaxis in Patients Treated for Acute Lymphoblastic Leukemia: A Comprehensive Systematic Review and Meta-Analysis

Acute lymphoblastic leukemia (ALL) is a common malignancy in children, often treated with intensive chemotherapy regimens. Venous thromboembolism (VTE) poses a significant risk during ALL treatment, leading to suboptimal outcomes. Thromboprophylaxis is crucial in mitigating this risk, but its efficacy and safety remain uncertain. This systematic review and meta-analysis aimed to evaluate the effectiveness of thromboprophylaxis in reducing VTE incidence during ALL treatment, focusing on antithrombin, apixaban, and enoxaparin. A systematic literature search adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Randomized controlled trials (RCTs) investigating thromboprophylaxis in ALL were included. Data extraction and quality appraisal were performed independently by three authors. Meta-analysis was conducted using Review Manager software. Three RCTs met the inclusion criteria. Apixaban, enoxaparin, and antithrombin were assessed in these trials. Meta-analysis revealed significantly reduced odds of VTE with thromboprophylaxis compared to standard care (odds ratio (OR): 0.47, 95% confidence interval (CI) 0.29-0.75; relative risk (RR): 0.52, 95% CI 0.33-0.83). However, no significant difference in bleeding risk was observed (OR: 1.33, 95% CI 0.42-4.21; RR: 1.32, 95% CI 0.43-4.07). Heterogeneity among studies was moderate. This study showed that thromboprophylaxis with apixaban, enoxaparin, or antithrombin significantly reduces VTE incidence during ALL treatment. Despite some limitations, including heterogeneity and potential biases, these findings support the adoption of tailored thromboprophylaxis strategies to improve outcomes in ALL patients. Further research is warranted to optimize these approaches and address remaining uncertainties.

Cost-effectiveness of open versus laparoscopic pancreatectomy: A nationwide, population-based study

BACKGROUND

Laparoscopic pancreatic resection is comparable to open pancreatic resection; however, cost-effectiveness analyses of laparoscopic pancreatic resection are scarce. The authors performed a population-based study investigating the cost-effectiveness of laparoscopic pancreatic resection versus open pancreatic resection.

METHODS

Data from 9,256 patients who received pancreaticoduodenectomy (66.8%) and distal pancreatectomy (33.2%) from 2016 to 2018 were retrieved from the Korean National Health Insurance Service. Events after pancreatectomy were categorized as no complication, complication, and death. Probabilities of each event and average cost during index admission and 1 year were utilized to calculate incremental cost-effectiveness ratio, the cost difference between two interventions divided by quality-adjusted life year. Quality-adjusted life year, a function of length and quality of life, was measured with utility values determined by researching literature.

RESULTS

Laparoscopic pancreatic resection was performed in 12.4% of pancreaticoduodenectomies and 53.4% of distal pancreatectomies. For pancreaticoduodenectomy, laparoscopic pancreatic resection was associated with an increase of 0.0022 quality-adjusted life years for index admission and 0.0023 quality-adjusted life years for 1 year compared with open pancreatic resection. The incremental cost was $321 for index admission and -$1,414 for 1 year, leading to an incremental cost-effectiveness ratio of $147,429 per quality-adjusted life year gained for index admission and -$614,965 per quality-adjusted life year gained for 1 year. For distal pancreatectomy, laparoscopic pancreatic resection improved 0.0131 quality-adjusted life years for index admission and 0.0285 quality-adjusted life years for index admission. The incremental cost was -$1,240 for index admission and -$5,875 for 1 year, leading to an incremental cost-effectiveness ratio of -$94,519 per quality-adjusted life year gained for index admission and -$206,351 for 1 year.

CONCLUSION

laparoscopic pancreatic resection was a cost-effective alternative to open pancreatic resection for pancreaticoduodenectomy and distal pancreatectomy, except for the higher cost of index admission for pancreaticoduodenectomy.

Direct oral anticoagulants versus low-molecular-weight heparin in patients with cancer-associated venous thrombosis: a cost-effectiveness analysis

Background

Direct oral anticoagulants (DOACs) have demonstrated clinical benefits and better patient adherence over low-molecular-weight heparin (LMWH) in treating patients with cancer-associated venous thrombosis (CAT). We aimed to compare the cost-effectiveness of DOACs against LMWH in patients with CAT from the perspective of the Hong Kong healthcare system.

Methods

A Markov state-transition model was performed to estimate the incremental cost-effectiveness ratio (ICER) per quality-adjusted life years (QALYs) for DOACs and LMWH in a hypothetical cohort of 10,000 patients with CAT over a 5-year lifetime horizon. The model was primarily based on the health states of no event, recurrent venous thromboembolism, bleeding, and death. Transition probabilities, relative risks, and utilities were derived from the literature. Resource cost data were obtained from the Hong Kong Hospital Authority. Deterministic and probabilistic sensitivity analyses tested the robustness of the results.

Results

Relative to LMWH, DOACs were associated with increased QALYs (1.52 versus 1.50) at a lower medical cost of USD 2,232 versus 8,224 in five years. The cost of LMWH was the main contributor to the outcome. Out of 10,000 simulated cases, DOACs were dominant in 15.8% and cost-effective in 42.1%, at the willingness-to-pay threshold of USD 148,392 per additional QALY.

Conclusions

DOACs were associated with greater QALY improvements and lower overall costs compared to LMWH. Accounting for uncertainty, DOACs were between cost-effective and dominant in 57.9% of cases. DOACs are a cost-effective alternative to LMWH in the management of CAT in Hong Kong.

Research progress on venous thrombosis development in patients with malignant tumors

The coexistence of venous thromboembolism (VTE) within patients with cancer, known as cancer-associated thrombosis (CAT), stands as a prominent cause of mortality in this population. Over recent years, the incidence of VTE has demonstrated a steady increase across diverse tumor types, influenced by several factors such as patient management, tumor-specific risks, and treatment-related aspects. Furthermore, mutations in specific genes have been identified as potential contributors to increased CAT occurrence in particular cancer subtypes. We conducted an extensive review encompassing pivotal historical and ongoing studies on CAT. This review elucidates the risks, mechanisms, reliable markers, and risk assessment methodologies that can significantly guide effective interventions in clinical practice.

Outcomes from a prospectively implemented protocol using apixaban after robot-assisted radical cystectomy

OBJECTIVES

To compare the safety and efficacy of oral apixaban with that of injectable enoxaparin after robot-assisted radical cystectomy (RARC) for venous thromboembolism (VTE) thromboprophylaxis.

MATERIALS AND METHODS

We conducted a retrospective review of prospectively collected data for all RARC patients treated at our tertiary care centre between 2018 and 2022. The study included two groups: patients who were subject to a prospectively implemented protocol from October 2021 to the present, comprising a 21-day postoperative course of apixaban 2.5 mg twice daily after discharge, and patients treated prior to October 2021 who received enoxaparin 40 mg daily. Baseline demographics and clinical characteristics, such as VTE (defined as deep vein thrombosis and pulmonary embolism), were analysed. The primary outcome was incidence of symptomatic VTE confirmed with definitive imaging within 90 days of RARC. Secondary outcomes included major bleeding, complications, readmission, and mortality within 30 days postoperatively. Descriptive statistics included baseline patient characteristics, operative information and complications. Differences in baseline characteristics and postoperative data were compared between groups. Multivariate logistic regression was used to determine associations between variables and the primary outcome.

RESULTS

A total of 124 patients received apixaban and 250 patients received enoxaparin prophylaxis. Ten patients (2.7%) experienced a VTE within 90 days postoperatively (two [1.6%] apixaban group vs eight [3.2%] enoxaparin group; P = 0.5). After patient stratification into European Association of Urology risk groups, no statistically significant difference in VTE rates was seen between groups in the apixaban (2.7% high- + intermediate-risk group vs 1.1% low-risk group; P = 0.5) and enoxaparin cohorts (4.3% high- + intermediate-risk group vs 2.5% low-risk group; P = 0.5). On multivariate logistic regression, no variables were associated with the development of the primary outcome.

CONCLUSION

Prophylaxis with apixaban and enoxaparin showed no statistically significant differences in VTE rates among RARC patients. Apixaban appears to be safe and effective for VTE prophylaxis after RARC.