Cost-utility analysis of management strategies after frontline treatment of women with epithelial ovarian cancer (339)

Abstract

<b>Objectives:</b> Performed a cost-utility analysis comparing maintenance therapies for advanced epithelial ovarian cancer to surveillance based on genetic mutation. <b>Methods:</b> We developed Markov models of post-frontline treatment disease course until death for women diagnosed with stage III-IV epithelial ovarian cancer to compare niraparib, olaparib, bevacizumab, and olaparib+bevacizumab with active surveillance. Four subgroups were analyzed: <i>(1)</i> all-comers, <i>(2) BRCA, (3) non-BRCA</i> homologous recombination deficiency (HRD), and <i>(4)</i> homologous recombination proficient (HR proficient). Transition probabilities for progression-free survival and adverse events were derived from randomized controlled trials, for all-cause mortality from US life tables, and for disease-specific mortality after recurrence from SEER. Utilities for maintenance treatment, grade 3-4 adverse events, disease-free off treatment, recurrence, and death were derived from ovarian cancer-specific time trade-off studies. Costs of treatment, adverse events, recurrence, and death were obtained from Centers for Medicare & Medicaid Services (CMS) fee schedules and published studies. Analysis was conducted from CMS's perspective. We considered a 3-month cycle length, a lifetime time horizon and applied a 3% annual discount rate. The primary outcome of interest was the incremental cost-effectiveness ratio (ICER), defined as the ratio of incremental cost to incremental quality-adjusted life-year (QALY). Uncertainty was evaluated using deterministic and probabilistic sensitivity analyses and represented by cost-effectiveness at willingness-to-pay (WTP) thresholds up to $200K/QALY. <b>Results:</b> For all-comers, surveillance and olaparib+bevacizumab were undominated (more effective and less costly), and the ICER of olaparib+bevacizumab in reference to surveillance was $182,823/ QALY. The probability of cost-effectiveness of olaparib+bevacizumab at a WTP threshold of $100K/QALY was 20%. For <i>BRCA</i> patients, surveillance and olaparib were nominated, and the ICER of olaparib was $49,896/QALY. The probability of olaparib being cost-effective at a WTP threshold of $100K/QALY was 71%. For non-<i>BRCA</i> HRD patients, surveillance and olaparib+bevacizumab were both undominated, and the ICER of olaparib+bevacizumab was $98,685/QALY. At a WTP threshold of $100,000/QALY, olaparib+bevacizumab had a higher probability of being cost-effective (48%) than niraparib (6%) or bevacizumab alone (4%). For HR proficient patients, surveillance was undominated and had the highest probability of being cost-effective at all WTP thresholds. <b>Conclusions:</b> Compared to active surveillance, olaparib+bevacizumab was the most cost-effective maintenance strategy for all-comers and non-<i>BRCA</i> HRD patients. At the same time, olaparib was most costeffective for women with <i>BRCA</i> mutations. The likelihood of any maintenance therapy being cost-effective for women with HR proficient disease was low.