Monte Carlo Probabilistic Sensitivity Analysis Research Articles

Cost-effectiveness of hepatic resection versus percutaneous radiofrequency ablation for early hepatocellular carcinoma

Both hepatic resection and radiofrequency ablation (RFA) are considered curative treatments for hepatocellular carcinoma (HCC), but their economic impact still remains not determined. Aim of the present study was to analyze the cost-effectiveness (CE) of these two strategies in early stage HCC (Milan criteria). As first step, a meta-analysis of the pertinent literature of the last decade was performed. Seventeen studies fulfilled the inclusion criteria: 3996 patients underwent resection and 4424 underwent RFA for early HCC. Data obtained from the meta-analysis were used to construct a Markov model. Costs were assessed from the health care provider perspective. A Monte Carlo probabilistic sensitivity analysis was used to estimate outcomes with distribution samples of 1000 patients for each treatment arm. In a 10-year perspective, for very early HCC (single nodule <2 cm) in Child-Pugh class A patients, RFA provided similar life-expectancy and quality-adjusted life-expectancy at a lower cost than resection and was the most cost-effective therapeutic strategy. For single HCCs of 3-5 cm, resection provided better life-expectancy and was more cost-effective than RFA, at a willingness-to-pay above €4200 per quality-adjusted life-year. In the presence of two or three nodules ≤3 cm, life-expectancy and quality-adjusted life-expectancy were very similar between the two treatments, but cost-effectiveness was again in favour of RFA. For very early HCC and in the presence of two or three nodules ≤3 cm, RFA is more cost-effective than resection; for single larger early stage HCCs, surgical resection remains the best strategy to adopt as a result of better survival rates at an acceptable increase in cost.

Cost-Effectiveness of Apixaban, Dabigatran, Rivaroxaban, and Warfarin for Stroke Prevention in Atrial Fibrillation

To estimate the cost-effectiveness of stroke prevention in patients with nonvalvular atrial fibrillation by using novel oral anticoagulants apixaban 5 mg, dabigatran 150 mg, and rivaroxaban 20 mg compared with warfarin. A Markov decision-analysis model was constructed using data from clinical trials to evaluate lifetime costs and quality-adjusted life-years of novel oral anticoagulants compared with warfarin. The modeled population was a hypothetical cohort of 70-year-old patients with nonvalvular atrial fibrillation, increased risk for stroke (CHADS2 ≥ 1), renal creatinine clearance ≥ 50 mL/min, and no previous contraindications to anticoagulation. The willingness-to-pay threshold was $50 000/quality-adjusted life-years gained. In the base case, warfarin had the lowest cost of $77 813 (SD, $2223), followed by rivaroxaban 20 mg ($78 738 ± $1852), dabigatran 150 mg ($82 719 ± $1959), and apixaban 5 mg ($85 326 ± $1512). Apixaban 5 mg had the highest quality-adjusted life-years estimate at 8.47 (SD, 0.06), followed by dabigatran 150 mg (8.41 ± 0.07), rivaroxaban 20 mg (8.26 ± 0.06), and warfarin (7.97 ± 0.04). In a Monte Carlo probabilistic sensitivity analysis, apixaban 5 mg, dabigatran 150 mg, rivaroxaban 20 mg, and warfarin were cost-effective in 45.1%, 40%, 14.9%, 0% of the simulations, respectively. In patients with nonvalvular atrial fibrillation and an increased risk of stroke prophylaxis, apixaban 5 mg, dabigatran 150 mg, and rivaroxaban 20 mg were all cost-effective alternatives to warfarin. The cost-effectiveness of novel oral anticoagulantss was dependent on therapy pricing in the United States and neurological events associated with rivaroxaban 20 mg.

PRS23 Economic Analysis of Vorizonazole, Amphotericine B and Caspofungin for Invasive Aspergilosis Patients in Private Hospitals in Dominican Republic

Invasive Aspergillosis (IA), a second cause of fungal invasive infections, is acquired by inhalation of spores. The primary infection is developed in lungs and it migrates to other structures. Mortality rate is 50% reaching up to 95% in bone marrow transplants. The aim of this study was to assess the cost-effectiveness (CE) of voriconazole, amphotericine B and caspofungin as first-line treatments for IA inmunosupressed adult patients in Dominican Republic, from the private health care's perspective. A cohort of patients with IA study was conducted using a decision-tree model to compare costs and effectiveness of of amphotericin B IV (15mg/kg/day) (basecase), caspofungin IV (initial dosage 70mg/day, maintenance dosage 50mg/day), and voriconazole IV (12mg/kg/day). Effectiveness measures were: clinical success rates, mortality rates, intensive care unit (ICU) length of stay (LOS) and hospital ward LOS. The model used a 12-week time horizon and only direct medical costs were considered. The epidemiologic data was collected from published literature. Local cost data (expressed in 2011 US$) was retrieved from Dominican Republic's private hospital official databases. Monte Carlo probabilistic sensitivity analysis (PSA) was constructed. Results showed voriconazole as the least expensive and most effective option for IA patients. ICU LOS was 7.59, 9.81, and 9.94 days for voriconazole, amphotericine B, and caspofungin, respectively. Hospital LOS was 15.4 days with voriconazole, 16.4 days with caspofungin and 16.5 with amphotericine B. Voriconazole obtained the lowest mortality rate (34.1%) in comparison to amphotericine B (50.9%) and caspofungin (44.7%). Furthermore, in regards to overall expected costs voriconazole resulted US$2711.25 and US$6881.05 less expensive than amphotericine B and caspofungin, respectively. CE analyses showed voriconazole as the cost-saving strategy. PSA results support these findings. In the private context of Dominican Republic, voriconazole resulted as a cost-saving option for treating IA inmunosupressed adult patients.

PRS24 Cost-Effectiveness Analysis of Voriconazole, Amphotericin B and Caspofungin for Invasive Aspergilosis Patients in Public Hospitals in Dominican Republic

Invasive aspergillosis (IA) is a major infectious complication in inmonusupressed patients. Its incidence ranges from 5 percent to more than 20 percent in high-risk groups. The aim of this study was to assess the cost-effectiveness (CE) of voriconazol, amphotericin B and caspofungin as first line treatments for IA adult inmunosupressed patients in Dominican Republic, from the public healthcare perspective. A decision-tree model was used to compare costs and effectiveness of amphotericin B (basecase) IV (15mg/kg/day), caspofungin IV (Initial dosage 70mg/day, maintenance dosage 50mg/day) and voriconazole IV (12mg/kg/day). Effectiveness measures were: clinical success rates, mortality rates, intensive care unit (ICU) length of stay (LOS) and hospital ward LOS. Effectiveness and epidemiologic data, was collected from published literature. Local public costs (2011 US$) were obtained from Dominican Republic's Social Security official databases. The model used a 12-week time horizon and only direct medical costs were considered. Monte Carlo probabilistic sensitivity analysis (PSA) was constructed. Voriconazole resulted as the least expensive and most effective option for IA patients. Clinical success rate was higher with voriconazole (56.6%) compared with amphotericin B (36.4%) and caspofungin (34.2%). Mortality rates were: 34.1% with voriconazole, 50.9% with amphotericin B and 44.7% with caspofungin. Considering ICU LOS against voriconazole, LOS resulted 2.22 and 2.35 days higher with amphotericin B and caspofungin, respectively. Hospital ward LOS was also higher with amphotericine B (16.4 days) and caspofungina (16.5 days) against voriconazole (15.4 days). Overall medical costs were: US$26,078.22 with voriconazole, US$29,240.17 with amphotericin B and US$33,514.01 with caspofungin. Cost effectiveness analyses showed voriconazole as the cost-saving strategy. PSA outcomes support the robustness of these findings. This is the first CE study for IA developed in Dominican Republic within the public sector. Voriconazole would generate savings over US$3000 per patient in the Dominican's clinical public context.

PRS21 Cost-Effectiveness Analysis of Linezolid Versus Vancomycin for Ventilator-Associated Pneumonia Patients in the Dominican Republic Public Case

Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation (MV) and is associated with an increased in mortality and in the intensive care unit (ICU) length of stay (LOS). The increasing prevalence of Methicillin Resistant Staphylococcus aureus in both hospital and community settings presents substantial higher costs which could be reduced using the most efficient empiric therapy. The aim of this study was to assess the cost-effectiveness (CE) of linezolid against vancomycin as an empiric therapy for VAP patients. The study included a cohort of adult patients with VAP in the ICU and it used a 12-week time horizon with the aid of a decision-tree model to compare costs and effectiveness of linezolid (600mg/12 hours) and vancomycin (15mg/Kg 12 hours) (standard of care). Effectiveness measures were: clinical success rates, mortality rates, ICU LOS and hospital LOS. The epidemiological data was collected from published literature and local costs (2011 US$) were obtained from public hospitals official databases. Only direct medical costs were considered (LOS, medication costs, hematologic, gastrointestinal and lab exams). Monte Carlo probabilistic sensitivity analysis (PSA) was developed. Results showed linezolid as a more effective and less expensive option for VAP adult patients in comparison with vancomycin. Mortality rate was lower with linezolid (10.13% vs. 15.74%) while clinical success rate was higher with linezolid (64%) against vancomicyn (59.5%). ICU LOS was 17.4 days for linezolid and 21.26 days for vancomycin. Hospital LOS was 8.44 days for linezolid and 9.43 days for vancomycin. Overall medical costs per patient were US$35,077.18 with linezolid and US$39,980.57 with vancomycin. CE analyses showed linezolid as cost-saving (dominant strategy). PSA outcomes support the robustness of these findings. The empiric use of linezolid in UCI for adults with VAP would result in economic and health benefits for the Dominican Republic's public environment.

PRS25 Economic Evaluation of Linezolid Vs Vancomycin for Ventilator-Associated Pneumonia Patients in Private Hospitals of Dominican Republic

of voriconazol, amphotericin B and caspofungin as first line treatments for IA adult inmunosupressed patients in Dominican Republic, from the public healthcare perspective. METHODS: A decision-tree model was used to compare costs and effectiveness of amphotericin B (basecase) IV (15mg/kg/day), caspofungin IV (Initial dosage 70mg/day, maintenance dosage 50mg/day) and voriconazole IV (12mg/kg/ day). Effectiveness measures were: clinical success rates, mortality rates, intensive care unit (ICU) length of stay (LOS) and hospital ward LOS. Effectiveness and epidemiologic data, was collected from published literature. Local public costs (2011 US$) were obtained from Dominican Republic=s Social Security official databases. The model used a 12-week time horizon and only direct medical costs were considered. Monte Carlo probabilistic sensitivity analysis (PSA) was constructed. RESULTS: Voriconazole resulted as the least expensive and most effective option for IA patients. Clinical success rate was higher with voriconazole (56.6%) compared with amphotericin B (36.4%) and caspofungin (34.2%). Mortality rates were: 34.1% with voriconazole, 50.9% with amphotericin B and 44.7% with caspofungin. Considering ICU LOS against voriconazole, LOS resulted 2.22 and 2.35 days higher with amphotericin B and caspofungin, respectively. Hospital ward LOS was also higher with amphotericine B (16.4 days) and caspofungina (16.5 days) against voriconazole (15.4 days). Overall medical costs were: US$26,078.22 with voriconazole, US$29,240.17 with amphotericin B and US$33,514.01 with caspofungin. Cost effectiveness analyses showed voriconazole as the cost-saving strategy. PSA outcomes support the robustness of these findings. CONCLUSIONS: This is the first CE study for IA developed in Dominican Republic within the public sector. Voriconazole would generate savings over US$3000 per patient in the Dominican’s clinical public context.

PIN51 A Cost-Effectiveness Analysis of Linezolid Versus Vancomycin for Ventilator-Associated Pneumonia Patients in Panama

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit (ICU). It's associated with significant morbidity, increasing the ICU and hospital length of stay (LOS), and raising overall costs. Panama′s statistics are similar to those reported in developed countries. Literature suggests that costs could be reduced using the most efficient empiric therapy. The aim of this study was to assess the cost-effectiveness (CE) of linezolid against generic vancomycin as an empiric therapy for VAP patients, from the health care payer's perspective. A decision-tree model was used to compare costs and effectiveness of linezolid (600mg/12 hours) and vancomycin (1g/ 12 hours) (comparator) for a cohort of patients with VAP. Effectiveness measures were: clinical and microbiological success rates, mortality rates, ICU LOS and overall costs. Effectiveness and epidemiologic data were collected from published literature. Local costs (2011 US$) were obtained from Panama′s Social Security official databases. The model used a 12-week time horizon and only direct medical costs were considered (hospital LOS, medication costs, hematologic, gastrointestinal and skin adverse events and lab exams). Monte Carlo probabilistic sensitivity analysis (PSA) was constructed. Results showed linezolid as more effective and less expensive option for VAP. Clinical success rate was higher with linezolid (64%) against vancomicyn, (59.5%). Mortality was lower with linezolid (10.13% vs. 15.74%). Average ICU LOSs was 17.4 days with linezolid and 21.26 days with vancomycin. Overall medical costs per patient were $19,507 with linezolid and $20,411 with vancomycin. CE analyses showed linezolid is the dominant strategy. Acceptability curves showed that linezolid would be cost-effective within <3 GDP per capita threshold. PSA outcomes support the robustness of these findings. This is the first CE study for VAP developed in Panamá. Linezolid resulted as the cost-saving option for treating VAP patients in the Panamanian clinical environment.

PIN59 A Cost-Effectiveness Analysis of Voriconazol, Anfotericine B and Caspofungin for Invasive Aspergilosis Patients in Panama

Invasive aspergilosis (IA) is a mycotic disease produce by Aspergillus sp and represents the second leading cause of invasive fungal infections. The mortality rate is about 50%. The aim of this study was to assess the cost-effectiveness (CE) of voriconazol, anfotericine B and caspofungin as first line treatments for IA adult patients in Panama, from the healthcare payer's perspective. A decision-tree model was used to compare costs and effectiveness of anfotericine B (comparator), caspofungin and voriconazol for a cohort of patients with IA. Effectiveness measures were: clinical success rates, mortality rates, intensive care unit (ICU) length of stay (LOS), hospital ward LOS and overall costs. Effectiveness and epidemiologic data were collected from published literature. Local costs (2011 US$) were obtained from Panama′s Social Security and Hospital Oncológico Nacional official databases. The model used a 12-week time horizon and only direct medical costs were considered. Monte Carlo probabilistic sensitivity analysis (PSA) was constructed. Results showed voriconazol as the most effective and least expensive option for IA. Clinical success rate was higher with voriconazol (56.6%) compared with anfotericine B (36.4%) and caspofungin (34.2%). Mortality rates were: 34.1% with voriconazol, 50.9% with anfotericine B and 44.7% with caspofungin. Average ICU LOSs was 7.59 days with voriconazol and 9.94 and 9.81 days with anfotericine B and caspofungin, respectively. Voriconazol also obtained the shortest ward LOS (15.96 days). Overall medical costs were $13,100 with voriconazol, $17,347 with anfotericine B and $13,716 with caspofungin. CE analyses showed voriconazol as the dominant strategy. Acceptability curves showed that voriconazol would be cost-effective within <3 GDP per capita threshold. PSA outcomes support the robustness of these findings. This is the first CE study for IA developed in Panamá. Voriconazol resulted as the cost-saving option for treating IA patients in the Panamanian clinical context.

Cost‐effectiveness of combination versus sequential docetaxel and carboplatin for the treatment of platinum‐sensitive, recurrent ovarian cancer

In a randomized controlled trial (RCT) of patients with recurrent, platinum-sensitive ovarian cancer, the combination weekly docetaxel and carboplatin was associated a with progression-free survival (PFS) of 13.7 months compared with 8.4 months for sequential, single-agent docetaxel followed by carboplatin. The objective of the current study was to construct a cost-utility model to compare these 2 regimens with the incorporation of prospectively collected quality-of-life (QoL) data. An RCT of concurrent docetaxel and carboplatin (cDC) versus docetaxel followed by carboplatin (sequential docetaxel and carboplatin [sDC]) was the basis for a Markov decision model, and the primary effectiveness outcome was PFS. Costs were estimated using US dollars based on Medicare reimbursements for chemotherapy regimens, bone marrow support, and management of adverse events. QoL data obtained using the Functional Assessment of Cancer Therapy-General questionnaire were converted to utilities. Costs and incremental cost-effectiveness ratios (ICERs) were reported in US dollars per quality-adjusted life year (QALY). Extensive 1-way sensitivity analyses and a Monte Carlo probabilistic sensitivity analysis were performed. The least expensive strategy was sDC, which cost an average of $20,381, compared with cDC, which cost an average of $25,122. cDC had an ICER of $25,239 per QALY compared with sDC. cDC remained cost-effective, with an ICER <$50,000 per QALY, over a range of costs and estimates. In Monte Carlo sensitivity analysis using a $50,000 per QALY willingness-to-pay threshold, cDC was either dominant or cost-effective with an ICER <$50,000 per QALY in 83% of simulations. Combined weekly cDC appeared to be cost-effective compared with sDC as treatment strategy for patients with platinum-sensitive ovarian cancer, even when accounting for slightly lower QoL during treatment.

Imaging-guided core needle biopsies (CNB) compared to surgical biopsies (SB) for soft tissue tumors: A cost-effectiveness analysis.

10073 Background: Core-needle biopsies are rarely used outside referral centers for diagnosis of soft tissue tumours, as many surgeons prefer to perform surgical biopsies. Methods: We had conducted a decision model analysis of the cost and the effectiveness of either strategies, i.e CNB first followed by SB if CNB provides technically poor non-representative tissue versus SB first followed by CNB if necessary. The main outcome was adequate surgery for soft tissue tumor. Utility was graded as follow: 1.0 if patients with sarcoma underwent planned surgery for sarcoma or if patients with benign tumor underwent adequate treatment, 0.5 if patients with benign tumor underwent large surgery as recommended for a sarcoma and 0 if a patient with sarcoma underwent a treatment as for benign tumor. Inputs were extracted from literature data (8 reports issued between 1996 and 2005). This analysis was conducted in societal perspective with one-month time-horizon (until time of curative- intent surgery). Model and variable uncertainties were explored by Monte-Carlo probabilistic sensitivity analysis. Results: According to literature data, SB provided representative tissue in 93% of cases, Se of 84% and Sp of 100%. CNB provided representative tissue in 89% of cases, Se of 96% and Sp of 95%. Mean cost of the strategy “SB first” was 3433 Euros (± 1148) and mean effectiveness was 93.5% (±3.7). Mean cost of the strategy CNB first was 2,052 Euros (± 449) and mean effectiveness was 96.5% (± 1.1). In the base-case analysis, the strategy CNB first was less expensive and beneficial. Results were confirmed by sensitivity analysis. Conclusions: The strategy “CNB first” provided a cost-saving of 1381 Euros (1,900 US$) per patient. In France (65 millions of inhabitant/4,000 sarcoma expected each year) this strategy may provide a total cost saving of about 2,700,000 Euros per year. Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Bayer

Cost-Utility Analysis of Von Willebrand Disease Screening in Adolescents with Menorrhagia.

Abstract 2476Poster Board II-453 Introduction:It is unknown whether it is cost effective to screen adolescents with menorrhagia for von Willebrand disease (VWD) prior to starting oral contraceptive pills (OCPs). Because OCPs can mask a diagnosis of VWD, a woman is at risk for potential future traumatic or surgical bleeding, once OCPs are stopped. We, therefore, designed a decision analysis model to evaluate the cost utility of VWD testing in adolescents with menorrhagia. Methods:A 20-year Markov decision analytic model was constructed to evaluate the cost-utility of two strategies: testing or not testing for VWD. The hypothetical patient is a 15-year-old female presenting with menorrhagia and a decision regarding VWD testing is made. The model includes probabilities of remaining well, suffering an acute menorrhagia bleeding event, surgical complications, OCP complications or dying. Probabilities, costs and utilities were estimated from published literature. The prevalence of type 1 VWD in adolescent females with menorrhagia was estimated to be 13%. We assumed all patients were treated with OCPs regardless of whether hemostatic testing was performed. All patients were assumed to have mild type I VWD, the most common subtype, and all were responsive to intravenous DDAVP. Probabilities of surgical complications in patients with and without VWD were based on adenotonsillectomy hemorrhage rates in children. The probability of acute menorrhagia bleeding necessitating hospitalization or red blood cell transfusion was estimated to be 1% in an adolescent with VWD and 0% in an adolescent with normal hemostatic testing. The sole complication from OCPs incorporated into this decision analytic model was acute deep vein thrombosis. Results:The cost of testing adolescents with menorrhagia for VWD was $1,638, vs. $1,251 for not testing for VWD. The effectiveness of not testing in quality-adjusted life-year (QALY) gained (14.237 QALY) was similar to the VWD testing strategy (14.246 QALY). Compared to not testing for VWD, screening for VWD had an incremental cost-effectiveness ratio (ICER) per QALY of $45,061/QALY, a value typically considered economically reasonable. In one-way sensitivity analysis, the outcome and ICER were most sensitive to the probabilities of an acute bleeding event, surgical complication, and the prevalence of VWD. Monte Carlo probabilistic sensitivity analysis, substituting input distributions rather than a single point estimate for the probabilities, costs and utilities, was also performed. Under this assumption, testing for VWD is a cost-effective strategy approximately 60% of the time when the cost-effectiveness threshold is $100,000/QALY. Conclusions:It is cost effective to perform VWD testing in adolescents presenting with menorrhagia prior to initiating OCPs. This is related to avoiding cost from postoperative and other bleeding when the diagnosis is masked by OCPs. Disclosures:No relevant conflicts of interest to declare.

Vancomycin flush as antibiotic prophylaxis for early catheter-related infections: a cost-effectiveness analysis

Early catheter-related infection (CRI) remains a severe complication in cancer patients. Some recent data suggest that vancomycin flush (VF) administered on the day of catheter insertion could reduce the CRI incidence, but VF could also induce infections by vancomycin-resistant Enterococcus sp. (VRE). So, we had conducted a decision model analysis of the cost and the effectiveness of three preventive strategies: absence of VF, VF in all cases, and VF in high-risk patients. The main outcome was absence of CRI and absence of VRE. Inputs were extracted from literature data. Variable uncertainty was explored by one- and two-way sensitivity analyses and best/worst case analysis. Model uncertainty was explored by Monte Carlo probabilistic sensitivity analysis. In base case, compared to absence of VF, the VF strategy in high-risk patients was the best strategy, in terms of cost (reduction cost estimated at $190 per patient) and benefit (probability of infection estimated at 98.1% versus 96.6%). The VF strategy in all cases was strongly dominated. These findings were confirmed by sensitivity analysis. VF in high-risk patients, such as defined in literature, is beneficial and cost-saving. Nevertheless, further investigations are needed to define better the probability and the cost of VRE, which are the two variables driving the model.

IMMUNOELECTROPHORETIC ANALYSIS

<h3>Objectives</h3> (1) To determine whether use of a PARP inhibitor or (2) <i>BRCA1/2</i> mutation testing followed by a PARP inhibitor for test positives is potentially cost-effective for maintenance treatment of platinum-sensitive recurrent high-grade serous ovarian cancer. <h3>Methods</h3> A modified Markov decision analysis compared 3 strategies: (1) observe; (2) olaparib to progression; (3) <i>BRCA1/2</i> mutation testing; treat mutation carriers with olaparib to progression. Progression-free survival and rates of adverse events were derived from a phase 2 randomized trial. Key assumptions are as follows: (1) 14% of patients harbor a <i>BRCA1/2</i> mutation; (2) progression-free survival of individuals treated with olaparib is improved for <i>BCRA1/2</i> carriers compared with noncarriers (estimated hazard ratio, approximately 0.4). Costs derived from national data were assigned to treatments, adverse events, and <i>BRCA1/2</i> test. Monte Carlo probabilistic sensitivity analysis was performed. <h3>Results</h3> Global olaparib was the most effective strategy, followed by <i>BRCA1/2</i> testing and no olaparib. <i>BRCA1/2</i> testing had an incremental cost-effectiveness ratio (ICER) of $193,442 per progression-free year of life saved (PF-YLS) compared to no olaparib, whereas global olaparib had an ICER of $234,128 per PF-YLS compared to <i>BRCA1/2</i> testing. At a 52% lower-than-baseline olaparib cost estimate of $3000 per month, <i>BRCA1/2</i> testing became potentially cost-effective compared with observation, with an ICER of $100,000 per PF-YLS. When strategy (1) was removed from the analysis, <i>BRCA1/2</i> testing was the preferred strategy. <h3>Conclusions</h3> The use of maintenance olaparib in women with high-grade serous ovarian cancer is not cost-effective regardless of whether <i>BRCA1/2</i> testing is used to direct treatment. However, <i>BRCA1/2</i> testing is a preferred strategy compared to global maintenance olaparib alone.