Economic Analysis of Neoadjuvant Chemotherapy Versus Primary Debulking Surgery for Advanced Epithelial Ovarian Cancer Using an Aggressive Surgical Paradigm

Abstract

Objectives: Neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) for advanced epithelial ovarian cancer (AEOC) remains controversial in the United States. Generalizability of existing trial results has been criticized because of less aggressive debulking procedures than commonly used in the United States. As a result, economic evaluations using input data from these trials may not accurately reflect costs and outcomes associated with more aggressive primary surgery. Using data from an ongoing trial performing aggressive debulking, we investigated the cost-effectiveness and cost-utility of NACT versus PDS for AEOC.

Methods: A decision tree model was constructed to estimate differences in short-term outcomes and costs for a hypothetical cohort of 15,000 AEOC patients (US annual incidence of AEOC) treated with NACT versus PDS over a 1-year time horizon from a Medicare payer perspective. Outcomes included costs per cancer-related death averted, life-years and quality-adjusted life-years (QALYs) gained. Base-case probabilities, costs, and utilities were based on the Surgical Complications Related to Primary or Interval Debulking in Ovarian Neoplasms trial. Base-case analyses assumed equivalent survival; threshold analysis estimated the maximum survival difference that would result in NACT being cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds. Probabilistic sensitivity analysis was used to characterize model uncertainty.

Results: Compared with PDS, NACT was associated with $142 million in cost savings, 1098 fewer cancer-related deaths, and 1355 life-years and 1715 QALYs gained, making it the dominant treatment strategy for all outcomes. In sensitivity analysis, NACT remained dominant in 99.3% of simulations. Neoadjuvant chemotherapy remained cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds if survival differences were less than 2.7 and 1.4 months, respectively.

Conclusions: In the short term, NACT is cost-saving with improved outcomes. However, if PDS provides a longer-term survival advantage, it may be cost-effective. Research is needed on the role of patient preferences in tradeoffs between survival and quality of life.

Figure 1. Decision tree comparing neoadjuvant chemotherapy to primary debulking surgery for bulky advanced ovarian cancer

The decision tree presented here describes the potential experiences of bulky AEOC patients who receive either PDS followed by ACT or NACT followed by IDS. Patients move left to right through the tree. The square node represents the decision to treat patients with PDS or NACT. Circle nodes represent the chance of a given outcome; triangle nodes represent a terminal event. Abbreviations: AEOC, advanced epithelial ovarian cancer; PDS, primary debulking surgery; NACT, neoadjuvant chemotherapy; IDS, interval debulking surgery; ACT, adjuvant chemotherapy *Early complications include those occurring ≤30 days post-surgery; Late complications include those occurring 1-6 months post-surgery.

Figure 2. Incremental cost-effectiveness ratio plane showing results of probabilistic sensitivity analysis of decision tree analysis of neoadjuvant chemotherapy versus primary debulking surgery for bulky advanced epithelial ovarian cancer

Abbreviations: QALY, quality-adjusted life-year