RESUMO
BACKGROUND: Parallel panel germline and somatic genetic testing of all patients with ovarian cancer (OC) can identify more pathogenic variants (PVs) that would benefit from PARP inhibitor (PARPi) therapy, and allow for precision prevention in unaffected relatives with PVs. In this study, we estimate the cost-effectiveness and population impact of parallel panel germline and somatic BRCA testing of all patients with OC incorporating PARPi therapy in the United Kingdom and the United States compared with clinical criteria/family history (FH)-based germline BRCA testing. We also evaluate the cost-effectiveness of multigene panel germline testing alone. METHODS: Microsimulation cost-effectiveness modeling using data from 2,391 (UK: n=1,483; US: n=908) unselected, population-based patients with OC was used to compare lifetime costs and effects of panel germline and somatic BRCA testing of all OC cases (with PARPi therapy) (strategy A) versus clinical criteria/FH-based germline BRCA testing (strategy B). Unaffected relatives with germline BRCA1/BRCA2/RAD51C/RAD51D/BRIP1 PVs identified through cascade testing underwent appropriate OC and breast cancer (BC) risk-reduction interventions. We also compared the cost-effectiveness of multigene panel germline testing alone (without PARPi therapy) versus strategy B. Unaffected relatives with PVs could undergo risk-reducing interventions. Lifetime horizon with payer/societal perspectives, along with probabilistic/one-way sensitivity analyses, are presented. Incremental cost-effectiveness ratio (ICER) and incremental cost per quality-adjusted life year (QALY) gained were compared with £30,000/QALY (UK) and $100,000/QALY (US) thresholds. OC incidence, BC incidence, and prevented deaths were estimated. RESULTS: Compared with clinical criteria/FH-based BRCA testing, BRCA1/BRCA2/RAD51C/RAD51D/BRIP1 germline testing and BRCA1/BRCA2 somatic testing of all patients with OC incorporating PARPi therapy had a UK ICER of £51,175/QALY (payer perspective) and £50,202/QALY (societal perspective) and a US ICER of $175,232/QALY (payer perspective) and $174,667/QALY (societal perspective), above UK/NICE and US cost-effectiveness thresholds in the base case. However, strategy A becomes cost-effective if PARPi costs decrease by 45% to 46% or if overall survival with PARPi reaches a hazard ratio of 0.28. Unselected panel germline testing alone (without PARPi therapy) is cost-effective, with payer-perspective ICERs of £11,291/QALY or $68,808/QALY and societal-perspective ICERs of £6,923/QALY or $65,786/QALY. One year's testing could prevent 209 UK BC/OC cases and 192 deaths, and 560 US BC/OC cases and 460 deaths. CONCLUSIONS: Unselected panel germline and somatic BRCA testing can become cost-effective, with a 45% to 46% reduction in PARPi costs. Regarding germline testing, unselected panel germline testing is highly cost-effective and should replace BRCA testing alone.
Assuntos
Carcinoma Epitelial do Ovário , Análise Custo-Benefício , Testes Genéticos , Mutação em Linhagem Germinativa , Neoplasias Ovarianas , Humanos , Feminino , Testes Genéticos/economia , Testes Genéticos/métodos , Carcinoma Epitelial do Ovário/genética , Carcinoma Epitelial do Ovário/economia , Carcinoma Epitelial do Ovário/diagnóstico , Carcinoma Epitelial do Ovário/tratamento farmacológico , Carcinoma Epitelial do Ovário/patologia , Neoplasias Ovarianas/genética , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/economia , Predisposição Genética para Doença , Proteína BRCA2/genética , Proteína BRCA1/genética , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Anos de Vida Ajustados por Qualidade de Vida , Inibidores de Poli(ADP-Ribose) Polimerases/uso terapêutico , Inibidores de Poli(ADP-Ribose) Polimerases/economia , RNA Helicases/genética , Adulto , Reino Unido/epidemiologia , Proteínas de Grupos de Complementação da Anemia de Fanconi/genética , Proteínas de Ligação a DNARESUMO
BACKGROUND: Patients may use crowdfunding to solicit donations, typically from multiple small donors using internet-based means, to offset the financial toxicity of cancer care. OBJECTIVE: To describe crowdfunding campaigns by gynecologic cancer patients and to compare campaign characteristics and needs expressed between patients with cervical, uterine, and ovarian cancer. STUDY DESIGN: We queried the public crowdfunding forum GoFundMe.com for "cervical cancer," "uterine cancer," and "ovarian cancer." The first 200 consecutive posts for each cancer type fundraising within the United States were analyzed. Data on campaign goals and needs expressed were manually extracted. Descriptive statistics and bivariate analyses were performed. RESULTS: Among the 600 fundraising pages, the median campaign goal was $10,000 [IQR $5000-$23,000]. Campaigns raised a median of 28.6% of their goal with only 8.7% of campaigns reaching their goal after a median of 54 days online. On average, ovarian cancer campaigns had higher monetary goals, more donors, and larger donation amounts than cervical cancer campaigns and raised more money than both cervical and uterine cancer campaigns. Campaigns were fundraising to support medical costs (80-85%) followed by lost wages (36-56%) or living expenses (27-41%). Cervical cancer campaigns reported need for non-medical costs more frequently than uterine or ovarian cancer campaigns. States without Medicaid expansions (31% of the national population) were over-represented among cervical cancer and uterine cancer, but not ovarian cancer campaigns. CONCLUSIONS: Crowdfunding pages reveal patients fundraising for out-of-pocket costs in the thousands of dollars and a wide range of unmet financial needs based on cancer type.
Assuntos
Obtenção de Fundos , Neoplasias dos Genitais Femininos , Humanos , Feminino , Obtenção de Fundos/economia , Neoplasias dos Genitais Femininos/economia , Neoplasias dos Genitais Femininos/terapia , Estados Unidos , Crowdsourcing/economia , Neoplasias do Colo do Útero/economia , Neoplasias do Colo do Útero/terapia , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/terapiaRESUMO
OBJECTIVES: We sought to quantify exposure to and financial impacts of poly (adenosine diphosphate ribose) polymerase inhibitor (PARPi) treatments for eventually withdrawn ovarian cancer indications. METHODS: We identified in Optum's deidentified Clinformatics® Data Mart database 1695 patients with ovarian cancer diagnoses who received olaparib, rucaparib, or niraparib between January 2015 and September 2021. We describe PARPi use and out-of-pocket, total healthcare, and PARPi spending among patients with ovarian cancer with 3 or more previous lines of therapy. RESULTS: Of the 1695 patients who received PARPi, 254 were estimated to have been heavily pretreated and exposed to eventually withdrawn indications. Cumulative total medical and pharmacy costs for these patients were $53 392 184; PARPi costs accounted for 34%. Median PARPi cost per patient was $43 347. Cumulative out-of-pocket costs totaled $533 281. CONCLUSIONS: Potential patient harm, including financial toxicity, might have been mitigated through more stringent drug approval requirements.
Assuntos
Gastos em Saúde , Neoplasias Ovarianas , Inibidores de Poli(ADP-Ribose) Polimerases , Humanos , Feminino , Inibidores de Poli(ADP-Ribose) Polimerases/economia , Inibidores de Poli(ADP-Ribose) Polimerases/uso terapêutico , Inibidores de Poli(ADP-Ribose) Polimerases/efeitos adversos , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/economia , Pessoa de Meia-Idade , Idoso , Piperidinas/economia , Piperidinas/uso terapêutico , Piperidinas/efeitos adversos , Indazóis/economia , Indazóis/uso terapêutico , Indazóis/efeitos adversos , Ftalazinas/economia , Ftalazinas/uso terapêutico , Ftalazinas/efeitos adversos , Indóis/economia , Indóis/uso terapêutico , Indóis/efeitos adversos , PiperazinasRESUMO
Background: Malignant bowel obstruction (MBO) due to peritoneal carcinomatosis (PC) is associated with poor outcomes. Optimal management for palliation remains unclear. This study aims to characterize nonoperative, procedural, and operative management strategies for MBO and evaluate its association with mortality and cost.Materials and Methods: ICD-10 coding identified patient admissions from the 2018 to 2019 National Inpatient Sample (NIS) for MBO with PC from gastrointestinal or ovarian primary cancers. Management was categorized as nonoperative, procedural, or surgical. Multivariate analysis was used to associate treatment with mortality and cost.Results: 356,316 patient admissions were identified, with a mean age of 63 years. Gender, race, and insurance status were similar among groups. Length of stay (LOS) was longest in the surgical group (surgical: 17 days; procedural: 14 days; nonoperative: 7 days; P = .001). In comparison to nonoperative, procedural and surgical patients had statistically higher hospital charges, post-discharge medical needs, palliative care consults, and admission to rehab centers. Mortality was 7% in nonoperative, 9% in procedural, and 8% in surgical (P = .007) groups. In adjusted analyses, older age, palliative care consult, and non-Medicare payer status were associated with higher mortality. Compared to nonoperative, procedural and surgical groups resulted in increased costs (procedural: $17K more; surgical: $30K more).Conclusions: Admissions for procedural and surgical treatment of MBO are associated with increased LOS, hospital costs, and discharge needs. Optimal management remains challenging. Clinicians must examine all options prior to recommending palliative interventions given a trend towards higher resource utilization and mortality.
Assuntos
Obstrução Intestinal , Tempo de Internação , Cuidados Paliativos , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Obstrução Intestinal/economia , Obstrução Intestinal/cirurgia , Obstrução Intestinal/mortalidade , Obstrução Intestinal/etiologia , Obstrução Intestinal/terapia , Cuidados Paliativos/economia , Idoso , Estados Unidos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Neoplasias Peritoneais/mortalidade , Neoplasias Peritoneais/economia , Neoplasias Peritoneais/terapia , Neoplasias Peritoneais/complicações , Neoplasias Gastrointestinais/complicações , Neoplasias Gastrointestinais/mortalidade , Neoplasias Gastrointestinais/cirurgia , Estudos Retrospectivos , Neoplasias Ovarianas/mortalidade , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/complicações , Custos Hospitalares/estatística & dados numéricosRESUMO
OBJECTIVE: To examine patient barriers and facilitators to PARP inhibitor (PARP-I) maintenance therapy in ovarian cancer. PARP-I improves survival in ovarian cancer, but these multi-year therapies cost around $100,000 annually and are under-prescribed. METHODS: We recruited patients with ovarian cancer treated with PARP-I maintenance therapy at an academic health system for a semi-structured interview. Patient demographics, including genetics and PARP-I cost, were self-reported. We assessed patient experiences with barriers and facilitators of PARP-I usage. Two team members used a thematic approach to analyze and identify key themes. RESULTS: In May 2022, we interviewed 10 patients (mean age = 65 years; 80% White; 60% with a germline genetic mutation). Patients paid on average $227.50 monthly for PARP-I, straining resources for some participants. While sampled patients were insured, all patients identified having no or inadequate insurance as a major barrier to PARP-I. At the same time, all participants prioritized clinical effectiveness over costs of care. Patients identified PARP-I delivery from specialty pharmacies, separate and different from other medications, as a potential barrier, but each had been able to navigate delivery. Patients expressed significant initial side effects of PARP-I as a potential barrier yet reported clinician communication and prompt dose reduction as facilitating continuation. CONCLUSIONS: Patients identified cost, restrictive pharmacy benefits, and initial side effects as barriers to PARP-I usage. Having insurance and a supportive care team were identified as facilitators. Enhancing communication about PARP-I cost and side effects could improve patient experience and receipt of evidence-based maintenance therapy in ovarian cancer.
Assuntos
Neoplasias Ovarianas , Inibidores de Poli(ADP-Ribose) Polimerases , Pesquisa Qualitativa , Humanos , Feminino , Inibidores de Poli(ADP-Ribose) Polimerases/economia , Inibidores de Poli(ADP-Ribose) Polimerases/uso terapêutico , Inibidores de Poli(ADP-Ribose) Polimerases/administração & dosagem , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/economia , Idoso , Pessoa de Meia-Idade , Quimioterapia de Manutenção/economia , Quimioterapia de Manutenção/métodosRESUMO
BACKGROUND AND AIMS OF THE STUDY: Due to its importance for treatment and potential prevention in family members, germline testing for BRCA1/2 in patients with newly diagnosed ovarian cancer is decisive and considered a standard of care. Maintenance therapy with poly(ADP-ribose) polymerase (PARP) inhibitors substantially improves progression-free survival in patients with BRCA mutations and homologous recombination-deficient tumours by inducing synthetic lethality. In Switzerland, they are licensed only for these patients. Therefore, it is crucial to test patients early while they are receiving adjuvant chemotherapy. This study aimed to determine whether genetic counselling followed by homologous recombination deficiency testing is feasible for initialising maintenance therapy within eight weeks and cost-effective in daily practice in Switzerland compared to somatic tumour analysis of all patients at diagnosis. METHODS: This single-centre retrospective study included 44 patients with newly diagnosed high-grade serous ovarian cancer of a Federation of Gynaecology and Obstetrics (FIGO) stage of IIIA-IVB diagnosed between 12/2020 and 12/2022. It collected the outcomes of genetic counselling, germline testing, and somatic Geneva test for homologous recombination deficiency. Delays in initiating maintenance therapy, total testing costs per patient, and progression-free survival were examined to assess feasibility and cost-effectiveness in clinical practice. RESULTS: Thirty-seven of 44 patients (84%) with newly diagnosed ovarian cancer received counselling, of which 34 (77%) were tested for germline BRCA and other homologous recombination repair gene mutations. Five (15%) BRCA and three (9%) other homologous recombination deficiency mutations were identified. Eleven of the remaining 26 patients (42%) had tumours with somatic homologous recombination deficiency. The mean time to the initiation of maintenance therapy of 5.2 weeks was not longer than in studies for market authorisation (SOLO1, PAOLA, and PRIMA). The mean testing costs per patient were 3880 Swiss Franks (CHF), compared to 5624 CHF if all patients were tested at diagnosis with the myChoice CDx test (p <0.0001). CONCLUSION: Using genetic counselling to consent patients with newly diagnosed ovarian cancer for germline testing fulfils the international gold standard. Subsequent somatic homologous recombination deficiency analysis complements testing and identifies more patients who will benefit from PARP inhibitor maintenance therapy. Contrary to previous health cost model studies, the procedure does not increase testing costs in the Swiss population and does not delay maintenance therapy. Therefore, all patients should be offered a primary germline analysis. The challenge for the future will be to ensure sufficient resources for prompt genetic counselling and germline testing.
Assuntos
Análise Custo-Benefício , Estudos de Viabilidade , Aconselhamento Genético , Neoplasias Ovarianas , Inibidores de Poli(ADP-Ribose) Polimerases , Humanos , Feminino , Neoplasias Ovarianas/genética , Neoplasias Ovarianas/economia , Estudos Retrospectivos , Aconselhamento Genético/economia , Pessoa de Meia-Idade , Suíça , Inibidores de Poli(ADP-Ribose) Polimerases/uso terapêutico , Inibidores de Poli(ADP-Ribose) Polimerases/economia , Mutação em Linhagem Germinativa , Idoso , Testes Genéticos/economia , Testes Genéticos/métodos , Adulto , Intervalo Livre de ProgressãoRESUMO
BACKGROUND: Our study aimed to establish 'real-world' performance and cost-effectiveness of ovarian cancer (OC) surveillance in women with pathogenic germline BRCA1/2 variants who defer risk-reducing bilateral salpingo-oophorectomy (RRSO). METHODS: Our study recruited 875 female BRCA1/2-heterozygotes at 13 UK centres and via an online media campaign, with 767 undergoing at least one 4-monthly surveillance test with the Risk of Ovarian Cancer Algorithm (ROCA) test. Surveillance performance was calculated with modelling of occult cancers detected at RRSO. The incremental cost-effectiveness ratio (ICER) was calculated using Markov population cohort simulation. RESULTS: Our study identified 8 OCs during 1277 women screen years: 2 occult OCs at RRSO (both stage 1a), and 6 screen-detected; 3 of 6 (50%) were ≤stage 3a and 5 of 6 (83%) were completely surgically cytoreduced. Modelled sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) for OC were 87.5% (95% CI, 47.3 to 99.7), 99.9% (99.9-100), 75% (34.9-96.8) and 99.9% (99.9-100), respectively. The predicted number of quality-adjusted life years (QALY) gained by surveillance was 0.179 with an ICER cost-saving of -£102,496/QALY. CONCLUSION: OC surveillance for women deferring RRSO in a 'real-world' setting is feasible and demonstrates similar performance to research trials; it down-stages OC, leading to a high complete cytoreduction rate and is cost-saving in the UK National Health Service (NHS) setting. While RRSO remains recommended management, ROCA-based surveillance may be considered for female BRCA-heterozygotes who are deferring such surgery.
Assuntos
Proteína BRCA1 , Proteína BRCA2 , Neoplasias Ovarianas , Feminino , Humanos , Proteína BRCA1/genética , Proteína BRCA2/genética , Diagnóstico Tardio , Predisposição Genética para Doença/epidemiologia , Células Germinativas/patologia , Mutação , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/epidemiologia , Neoplasias Ovarianas/genética , Ovariectomia , Medicina Estatal/economia , Salpingectomia , Reino Unido/epidemiologia , Vigilância da População , Análise de Custo-EfetividadeRESUMO
BACKGROUND: Gynecologic oncologists should be aware of the option of conception through IVF/PGT-M for families with high BRCA related morbidity or mortality. Our objective was to investigate the cost-effectiveness of preimplantation genetic testing for selection and transfer of BRCA negative embryo in BRCA mutation carriers compared to natural conception. METHODS: Cost-effectiveness of two strategies, conception through IVF/PGT-M and BRCA negative embryo transfer versus natural conception with a 50% chance of BRCA positive newborn for BRCA mutation carriers was compared using a Markovian process decision analysis model. Costs of the two strategies were compared using quality adjusted life years (QALYs'). All costs were discounted at 3%. Incremental cost effectiveness ratio (ICER) compared to willingness to pay threshold was used for cost-effectiveness analysis. RESULTS: IVF/ PGT-M is cost-effective with an ICER of 150,219 new Israeli Shekels, per QALY gained (equivalent to 44,480 USD), at a 3% discount rate. CONCLUSIONS: IVF/ PGT-M and BRCA negative embryo transfer compared to natural conception among BRCA positive parents is cost effective and may be offered for selected couples with high BRCA mutation related morbidity or mortality. Our results could impact decisions regarding conception among BRCA positive couples and health care providers.
Assuntos
Proteína BRCA2/genética , Triagem de Portadores Genéticos , Diagnóstico Pré-Implantação , Adulto , Neoplasias da Mama/economia , Neoplasias da Mama/epidemiologia , Neoplasias da Mama/genética , Análise Custo-Benefício , Transferência Embrionária/economia , Transferência Embrionária/métodos , Feminino , Fertilização in vitro/economia , Fertilização in vitro/métodos , Triagem de Portadores Genéticos/economia , Triagem de Portadores Genéticos/métodos , Humanos , Recém-Nascido , Israel/epidemiologia , Masculino , Mutação , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/epidemiologia , Neoplasias Ovarianas/genética , Gravidez , Diagnóstico Pré-Implantação/economia , Diagnóstico Pré-Implantação/métodos , Anos de Vida Ajustados por Qualidade de Vida , Seleção Genética/genética , Análise de SobrevidaRESUMO
OBJECTIVE: To assess preferences of women with ovarian cancer regarding features of available anti-cancer regimens for platinum-resistant, biomarker-positive disease, with an emphasis on oral PARP inhibitor and standard intravenous (IV) chemotherapy regimens. METHODS: A discrete-choice-experiment preferences survey was designed, tested, and administered to women with ovarian cancer, with 11 pairs of treatment profiles defined using seven attributes (levels/ranges): regimen (oral daily, IV weekly, IV monthly); probability of progression-free (PFS) at 6 months (40%-60%); probability of PFS at 2 years (10%-20%); nausea (none, moderate); peripheral neuropathy (none, mild, moderate); memory problems (none, mild); and total out-of-pocket cost ($0 to $10,000). RESULTS: Of 123 participants, 38% had experienced recurrence, 25% were currently receiving chemotherapy, and 18% were currently taking a PARP inhibitor. Given attributes and levels, the relative importance weights (sum 100) were: 2-year PFS, 28; cost, 27; 6-month PFS, 19; neuropathy,14; memory problems, nausea, and regimen, all ≤5. To accept moderate neuropathy, participants required a 49% (versus 40%) chance of PFS at 6 months or 14% (versus 10%) chance at 2 years. Given a 3-way choice where PFS and cost were equal, 49% preferred a monthly IV regimen causing mild memory problems, 47% preferred an oral regimen causing moderate nausea, and 4% preferred a weekly IV regimen causing mild memory and mild neuropathy. CONCLUSIONS: These findings challenge the assumption that oral anti-cancer therapies are universally preferred by patients and demonstrate that there is no "one size fits all" regimen that is preferable to women with ovarian cancer when considering recurrence treatment regimens.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Recidiva Local de Neoplasia/tratamento farmacológico , Neoplasias Ovarianas/tratamento farmacológico , Preferência do Paciente/estatística & dados numéricos , Administração Intravenosa , Administração Oral , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/economia , Custos de Medicamentos , Feminino , Humanos , Transtornos da Memória/induzido quimicamente , Transtornos da Memória/diagnóstico , Transtornos da Memória/psicologia , Pessoa de Meia-Idade , Náusea/induzido quimicamente , Náusea/diagnóstico , Náusea/psicologia , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/economia , Recidiva Local de Neoplasia/mortalidade , Síndromes Neurotóxicas/diagnóstico , Síndromes Neurotóxicas/etiologia , Síndromes Neurotóxicas/psicologia , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/mortalidade , Preferência do Paciente/economia , Inibidores de Poli(ADP-Ribose) Polimerases/administração & dosagem , Inibidores de Poli(ADP-Ribose) Polimerases/efeitos adversos , Inibidores de Poli(ADP-Ribose) Polimerases/economia , Intervalo Livre de Progressão , Índice de Gravidade de Doença , Inquéritos e Questionários/estatística & dados numéricosRESUMO
BACKGROUND: Opportunistic salpingectomy at the time of hysterectomy or as an alternative to bilateral tubal ligation may reduce the incidence of ovarian cancer, because it has been demonstrated that most serous ovarian cancers begin in the fallopian tubes. However, salpingectomy at the time of sterilization is not always financially covered by third-party payers, and this represents a barrier to adoption. Routine salpingectomy has become more common but is not always practiced at the time of hysterectomy. OBJECTIVE: This study aimed to determine the impact of opportunistic salpingectomy as an alternative tubal ligation and routine salpingectomy at the time of hysterectomy on ovarian cancer mortality and overall cost. STUDY DESIGN: An 8-state Markov state transition model was constructed, including hysterectomy, tubal ligation, and ovarian cancer. Transition probabilities were informed by previously reported population data and include age-adjusted rates of elective sterilization and hysterectomy. This model was used to predict ovarian cancer incidence and the cost effectiveness of opportunistic salpingectomy. Testing of this model suggested that it accurately predicted overall life expectancy and closely predicted the rate of hysterectomy in the population. The model may underestimate the rate of tubal sterilization, making it conservative with respect to the benefits of salpingectomy. RESULTS: The recursive Markov model was run from ages 20 to 85 years in 1-year intervals with a half step correction and included age-adjusted rates of tubal ligation, hysterectomy (with and without oophorectomy), and ovarian cancer. The model predicts that opportunistic salpingectomy at the time of tubal ligation will reduce ovarian cancer mortality by 8.13%. Opportunistic salpingectomy at the time of hysterectomy will reduce ovarian cancer mortality by 6.34% for a combined decrease of 14.5%. Both strategies are cost effective when considering only the cost of the opportunistic salpingectomy. The excess cost of opportunistic salpingectomy at the time of tubal ligation was $433.91 with an incremental cost-effective ratio of $6401 per life-year and $5469 per quality-adjusted life year gained when adjusting for ovarian cancer with a utility of 0.64. The incremental cost-effective ratio for opportunistic salpingectomy during hysterectomy at a cost of $124.70 was $2006 per life-year and $1667 per quality-adjusted life year. When considering the impact of ovarian cancer prevention with respect to the cost of ovarian cancer treatment, opportunistic salpingectomy may produce a substantial healthcare savings. Utilizing a 3% discount rate, it is estimated that the total savings for universal salpingectomy could be as high as $445 million annually in the United States. A sensitivity analysis around the benefit of opportunistic salpingectomy suggests that this procedure will be cost effective even if salpingectomy provides only a modest reduction in the risk of ovarian cancer. CONCLUSION: It is estimated that universal opportunistic salpingectomy may prevent 1854 deaths per year from ovarian cancer and may reduce healthcare costs. Given these data, universal opportunistic salpingectomy should be considered at the time of tubal ligation and hysterectomy and covered by third-party payers.
Assuntos
Carcinoma Epitelial do Ovário/prevenção & controle , Cesárea/métodos , Custos de Cuidados de Saúde , Histerectomia/métodos , Neoplasias Ovarianas/prevenção & controle , Procedimentos Cirúrgicos Profiláticos/métodos , Salpingectomia/métodos , Esterilização Tubária/métodos , Adolescente , Adulto , Idoso , Carcinoma Epitelial do Ovário/economia , Carcinoma Epitelial do Ovário/mortalidade , Análise Custo-Benefício , Feminino , Humanos , Cobertura do Seguro/economia , Seguro Saúde/economia , Cadeias de Markov , Pessoa de Meia-Idade , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/mortalidade , Procedimentos Cirúrgicos Profiláticos/economia , Anos de Vida Ajustados por Qualidade de Vida , Salpingectomia/economia , Adulto JovemRESUMO
Objectives: To determine whether olaparib maintenance therapy, used with and without restriction by BRCA1/2 mutation status, is cost-effective at the population level for platinum-sensitive relapsed ovarian cancer in Singapore.Methods: A partitioned survival model compared three management strategies: 1) treat all patients with olaparib; 2) test for germline BRCA1/2 mutation, followed by targeted olaparib use in mutation carriers only; 3) observe all patients. Mature overall survival (OS) data from Study 19 and a 15-year time horizon were used and direct medical costs were applied. Sensitivity analyses were conducted to explore uncertainties.Results: Treating all patients with olaparib was the most costly and effective strategy, followed by targeted olaparib use, and observation of all patients. Base-case incremental cost-effectiveness ratios (ICERs) for all-olaparib and targeted use strategies were SGD133,394 (USD100,926) and SGD115,736 (USD87,566) per quality-adjusted life year (QALY) gained, respectively, compared to observation. ICERs were most sensitive to the cost of olaparib, time horizon and discount rate for outcomes. When these parameters were varied, ICERs remained above SGD92,000 (USD69,607)/QALY.Conclusions: At the current price, olaparib is not cost-effective when used with or without restriction by BRCA1/2 mutation status in Singapore, despite taking into account potential OS improvement over a long time horizon.
Assuntos
Terapia de Alvo Molecular , Neoplasias Ovarianas/tratamento farmacológico , Ftalazinas/administração & dosagem , Piperazinas/administração & dosagem , Inibidores de Poli(ADP-Ribose) Polimerases/administração & dosagem , Proteína BRCA1/genética , Proteína BRCA2/genética , Análise Custo-Benefício , Feminino , Humanos , Mutação , Recidiva Local de Neoplasia , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/genética , Ftalazinas/economia , Piperazinas/economia , Inibidores de Poli(ADP-Ribose) Polimerases/economia , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Singapura , Análise de Sobrevida , Fatores de TempoRESUMO
OBJECTIVE: To determine if laparoscopy is a cost-effective way to assess disease resectability in patients with newly diagnosed advanced ovarian cancer. METHODS: A cost-effectiveness analysis from a health care payer perspective was performed comparing two strategies: (1) a standard evaluation strategy, where a conventional approach to treatment planning was used to assign patients to either primary cytoreduction (PCS) or neoadjuvant chemotherapy with interval cytoreduction (NACT), and (2) a laparoscopy strategy, where patients considered candidates for PCS would undergo laparoscopy to triage between PCS or NACT based on the laparoscopy-predicted likelihood of complete gross resection. A microsimulation model was developed that included diagnostic work-up, surgical and adjuvant treatment, perioperative complications, and progression-free survival (PFS). Model parameters were derived from the literature and our published data. Effectiveness was defined in quality-adjusted PFS years. Results were tested with deterministic and probabilistic sensitivity analysis (PSA). The willingness-to-pay (WTP) threshold was set at $50,000 per year of quality-adjusted PFS. RESULTS: The laparoscopy strategy led to additional costs (average additional cost $7034) but was also more effective (average 4.1 months of additional quality-adjusted PFS). The incremental cost-effectiveness ratio (ICER) of laparoscopy was $20,376 per additional year of quality-adjusted PFS. The laparoscopy strategy remained cost-effective even as the cost added by laparoscopy increased. The benefit of laparoscopy was influenced by mitigation of serious complications and their associated costs. The laparoscopy strategy was cost-effective across a range of WTP thresholds. CONCLUSIONS: Performing laparoscopy is a cost-effective way to improve primary treatment planning for patients with untreated advanced ovarian cancer.
Assuntos
Laparoscopia/economia , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/cirurgia , Análise Custo-Benefício , Procedimentos Cirúrgicos de Citorredução/economia , Procedimentos Cirúrgicos de Citorredução/métodos , Feminino , Humanos , Laparoscopia/métodos , Modelos Econômicos , Modelos Estatísticos , Neoplasias Ovarianas/economia , Estados UnidosAssuntos
Carcinoma Epitelial do Ovário/terapia , Quimioterapia Intraperitoneal Hipertérmica/métodos , Terapia Neoadjuvante/métodos , Recidiva Local de Neoplasia/epidemiologia , Neoplasias Ovarianas/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/economia , Carcinoma Epitelial do Ovário/economia , Carcinoma Epitelial do Ovário/mortalidade , Carcinoma Epitelial do Ovário/patologia , Ensaios Clínicos Fase III como Assunto , Análise Custo-Benefício , Procedimentos Cirúrgicos de Citorredução , Intervalo Livre de Doença , Feminino , Custos Hospitalares , Humanos , Quimioterapia Intraperitoneal Hipertérmica/efeitos adversos , Quimioterapia Intraperitoneal Hipertérmica/economia , Terapia Neoadjuvante/efeitos adversos , Terapia Neoadjuvante/economia , Recidiva Local de Neoplasia/prevenção & controle , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/mortalidade , Neoplasias Ovarianas/patologia , Ovário/patologia , Ovário/cirurgia , Seleção de Pacientes , Intervalo Livre de Progressão , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Tempo para o TratamentoRESUMO
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.
Assuntos
Cistadenocarcinoma Seroso/tratamento farmacológico , Letrozol/administração & dosagem , Neoplasias Ovarianas/tratamento farmacológico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Canadá , Quimioterapia Adjuvante , Análise Custo-Benefício , Cistadenocarcinoma Seroso/economia , Cistadenocarcinoma Seroso/patologia , Cistadenocarcinoma Seroso/cirurgia , Técnicas de Apoio para a Decisão , Feminino , Humanos , Letrozol/economia , Quimioterapia de Manutenção , Cadeias de Markov , Pessoa de Meia-Idade , Modelos Econômicos , Terapia Neoadjuvante , Estadiamento de Neoplasias , Compostos Organoplatínicos/administração & dosagem , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/patologia , Neoplasias Ovarianas/cirurgiaRESUMO
With the growing technical ease and reduction in genetic screening costs, whole population BRCA screening may be a feasible option. Our objective was to investigate the cost effectiveness of whole population screening for BRCA mutations in Israel, for varying degrees of BRCA carrier state. Lifetime costs of whole female population screening for BRCA mutation carrier state versus nonscreening were compared using a Markovian process decision analysis model. Model parameters including ovarian and breast cancer risks were obtained from previously published data. Screening and other treatment-related costs were received from the Israeli Ministry of Health pricing list according to specified codes. Quality-adjusted life years were used for cost-effectiveness analysis. Sensitivity analysis was conducted to evaluate model uncertainties, specifically varying degrees of BRCA prevalence. Results show that whole population BRCA screening in Israel is cost effective across a wide range of BRCA prevalence rates with an incremental cost-effectiveness ratio of 81,493 new Israeli Shekels for a BRCA prevalence of 2.5%, increasing to 250,000 new Israeli Shekels for a 0.75% prevalence rate, per quality-adjusted life year gained. Discount rate and population BRCA prevalence and rate of risk reduction salpingo-oophorectomy are the most influential parameters in the model. Whole population screening for BRCA mutations should be offered as part of general health screening strategies by national medical insurance providers, even for non-Ashkenazi Jews. Our algorithm can be applied for other countries, adjusting local costs of screening and treatment. PREVENTION RELEVANCE: Whole population BRCA mutation screening in Israel is cost effective across a wide prevalence rate and should be offered as part of general health screening strategies by national medical insurance providers for cancer prevention.
Assuntos
Proteína BRCA1/genética , Proteína BRCA2/genética , Neoplasias da Mama/economia , Análise Custo-Benefício , Testes Genéticos/economia , Mutação em Linhagem Germinativa , Neoplasias Ovarianas/economia , Adulto , Biomarcadores Tumorais/genética , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/epidemiologia , Neoplasias da Mama/prevenção & controle , Feminino , Testes Genéticos/métodos , Humanos , Israel/epidemiologia , Pessoa de Meia-Idade , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/epidemiologia , Neoplasias Ovarianas/prevenção & controle , Anos de Vida Ajustados por Qualidade de VidaRESUMO
Importance: There are large randomized clinical trials-SOLO-1 (Olaparib Maintenance Monotherapy in Patients With BRCA Mutated Ovarian Cancer Following First Line Platinum Based Chemotherapy [December 2018]), PRIMA (A Study of Niraparib Maintenance Treatment in Patients With Advanced Ovarian Cancer Following Response on Front-Line Platinum-Based Chemotherapy [September 2019]), and PAOLA-1 (Platine, Avastin and Olaparib in 1st Line [December 2019])-reporting positive efficacy results for maintenance regimens for women with primary, advanced epithelial ovarian cancer. The findings resulted in approval by the US Food and Drug Administration of the treatments studied as of May 2020. However, there are pressing economic considerations given the many eligible patients and substantial associated costs. Objective: To evaluate the cost-effectiveness of maintenance strategies for patients with (1) a BRCA variant, (2) homologous recombination deficiency without a BRCA variant, or (3) homologous recombination proficiency. Design, Setting, and Participants: In this economic evaluation of the US health care sector using simulated patients with primary epithelial ovarian cancer, 3 decision trees were developed, one for each molecular signature. The maintenance strategies evaluated were olaparib (SOLO-1), olaparib-bevacizumab (PAOLA-1), bevacizumab (PAOLA-1), and niraparib (PRIMA). Base case 1 assessed olaparib, olaparib-bevacizumab, bevacizumab, and niraparib vs observation of a patient with a BRCA variant. Base case 2 assessed olaparib-bevacizumab, bevacizumab, and niraparib vs observation in a patient with homologous recombination deficiency without a BRCA variant. Base case 3 assessed olaparib-bevacizumab, bevacizumab, and niraparib vs observation in a patient with homologous recombination proficiency. The time horizon was 24 months. Costs were estimated from Medicare claims, wholesale acquisition prices, and published sources. Probabilistic sensitivity analyses with microsimulation were then conducted to account for uncertainty and assess model stability. One-way sensitivity analyses were also performed. The study was performed from January through June 2020. Main Outcomes and Measures: Incremental cost-effectiveness ratios (ICERs) in US dollars per progression-free life-year saved (PF-LYS). Results: Assuming a willingness-to-pay threshold of $100â¯000/PF-LYS, none of the drugs could be considered cost-effective compared with observation. In the case of a patient with a BRCA variant, olaparib was the most cost-effective (ICER, $186â¯777/PF-LYS). The third-party payer price per month of olaparib would need to be reduced from approximately $17â¯000 to $9000 to be considered cost-effective. Olaparib-bevacizumab was the most cost-effective in the case of a patient with homologous recombination deficiency without a BRCA variant (ICER, $629â¯347/PF-LYS), and bevacizumab was the most cost-effective in the case of patient with homologous recombination proficiency (ICER, $557â¯865/PF-LYS). Even at a price of $0 per month, niraparib could not be considered cost-effective as a maintenance strategy for patients with homologous recombination proficiency. Conclusions and Relevance: The findings of this study suggest that, at current costs, maintenance therapy for primary ovarian cancer is not cost-effective, regardless of molecular signature. For certain therapies, lowering the drug price alone may not make them cost-effective.
Assuntos
Bevacizumab , Carcinoma Epitelial do Ovário , Indazóis , Quimioterapia de Manutenção , Neoplasias Ovarianas , Ftalazinas , Piperazinas , Piperidinas , Antineoplásicos Imunológicos/economia , Antineoplásicos Imunológicos/uso terapêutico , Bevacizumab/economia , Bevacizumab/uso terapêutico , Carcinoma Epitelial do Ovário/tratamento farmacológico , Carcinoma Epitelial do Ovário/economia , Carcinoma Epitelial do Ovário/genética , Carcinoma Epitelial do Ovário/patologia , Metodologias Computacionais , Análise Custo-Benefício , Feminino , Genes BRCA1 , Genes BRCA2 , Recombinação Homóloga , Humanos , Indazóis/economia , Indazóis/uso terapêutico , Quimioterapia de Manutenção/economia , Quimioterapia de Manutenção/métodos , Medicare/estatística & dados numéricos , Estadiamento de Neoplasias , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/genética , Neoplasias Ovarianas/patologia , Ftalazinas/economia , Ftalazinas/uso terapêutico , Piperazinas/economia , Piperazinas/uso terapêutico , Piperidinas/economia , Piperidinas/uso terapêutico , Estados UnidosRESUMO
OBJECTIVES: Clinical trials evaluating universal PARP inhibitor (PARPi) frontline maintenance therapy for advanced stage ovarian cancer have reported progression-free survival (PFS) benefit. It is unclear whether PARPi maintenance therapy will universally enhance value (clinical benefits relative to cost of delivery). We compared a "PARPi-for-all" to a biomarker-directed frontline maintenance therapy approach as a value-based care strategy. METHODS: The cost of two frontline PARPi maintenance strategies, PARPi-for-all and biomarker-directed maintenance, was compared using modified Markov decision models simulating the study designs of the PRIMA, VELIA, and, PAOLA-1 trials. Outcomes of interest included overall costs and incremental cost-effectiveness ratios (ICERs) reported in US dollars per quality adjusted progression-free life-year (QA-PFY) gained. RESULTS: PARPi-for-all was more costly and provided greater PFS benefit than a biomarker-directed strategy for each trial. The mean cost per patient for the PARPi-for-all strategy was $166,269, $286,715, and $366,506 for the PRIMA, VELIA, and PAOLA-1 models, respectively. For the biomarker-directed strategy, the mean cost per patient was $98,188, $167,334, and $260,671 for the PRIMA, VELIA, and PAOLA-1 models. ICERs of PARPi-for-all compared to biomarker-directed maintenance were: $593,250/QA-PFY (PRIMA), $1,512,495/QA-PFY (VELIA), and $3,347,915/QA-PFY (PAOLA-1). At current drug pricing, there is no PFS improvement in a biomarker negative cohort that would make PARPi-for-all cost-effective compared to biomarker-directed maintenance. CONCLUSIONS: This study highlights the high costs of universal PARPi maintenance treatment, compared with a biomarker-directed PARPi strategy. Maintenance therapy in the front-line setting should be reserved for those with germline or somatic HRD mutations until the cost of therapy is significantly reduced.
Assuntos
Biomarcadores Tumorais/economia , Carcinoma Epitelial do Ovário/tratamento farmacológico , Quimioterapia de Manutenção/economia , Neoplasias Ovarianas/tratamento farmacológico , Inibidores de Poli(ADP-Ribose) Polimerases/economia , Carcinoma Epitelial do Ovário/economia , Análise Custo-Benefício , Feminino , Humanos , Quimioterapia de Manutenção/métodos , Método de Monte Carlo , Neoplasias Ovarianas/economia , Intervalo Livre de ProgressãoRESUMO
OBJECTIVES: 1.) To compare frequency of HIPEC use in ovarian cancer treatment before and after publication of the phase III study by van Driel et al. in January 2018. 2.) To compare associated rates of hospital-based outcomes, including length of stay, intensive care unit (ICU) admission, complications, and costs in ovarian cancer surgery with or without HIPEC. METHODS: We queried Vizient's administrative claims database of 550 US hospitals for ovarian cancer surgeries from January 2016-January 2020 using ICD-10 diagnosis and procedure codes. Sodium thiosulfate administration was used to identify HIPEC cases according to the published protocol. Student t-tests and relative risk (RR) were used to compare continuous variables and contingency tables, respectively. RESULTS: 152 ovarian cancer patients had HIPEC at 39 hospitals, and 20,014 ovarian cancer patients had surgery without HIPEC at 256 hospitals. Following the trial publication, 97% of HIPEC cases occurred. During the index admission, HIPEC patients had longer median length of stay (8.4 vs. 5.7 days, p < 0.001) and higher percentage of ICU admissions (63.1% vs. 11.0%, p < 0.001) and complication rates (RR = 1.87, p = 0.002). Index admission direct costs ($21,825 vs. $12,038, p < 0.001) and direct cost index (observed/expected costs) (1.87 vs. 1.11, p < 0.001) were also greater in the HIPEC patients. No inpatient deaths or 30-day readmissions were identified after HIPEC. CONCLUSIONS: Use of HIPEC for ovarian cancer increased in the US after publication of a phase III clinical trial in a high-impact journal, though the absolute number of cases remains modest. Incorporation of HIPEC was associated with increased cost, hospital length of stay, ICU admission, and hospital-acquired complication rates. Further studies are needed in order to evaluate long-term outcomes, including morbidity and survival.
Assuntos
Carcinoma Epitelial do Ovário/terapia , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Quimioterapia Intraperitoneal Hipertérmica/tendências , Neoplasias Ovarianas/terapia , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Carcinoma Epitelial do Ovário/economia , Carcinoma Epitelial do Ovário/mortalidade , Ensaios Clínicos Fase III como Assunto , Feminino , Custos Hospitalares/estatística & dados numéricos , Custos Hospitalares/tendências , Humanos , Quimioterapia Intraperitoneal Hipertérmica/efeitos adversos , Quimioterapia Intraperitoneal Hipertérmica/economia , Quimioterapia Intraperitoneal Hipertérmica/estatística & dados numéricos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/estatística & dados numéricos , Unidades de Terapia Intensiva/tendências , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/mortalidade , Ovário/efeitos dos fármacos , Ovário/cirurgia , Admissão do Paciente/economia , Admissão do Paciente/estatística & dados numéricos , Admissão do Paciente/tendências , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To characterize factors associated with high-cost inpatient admissions for ovarian cancer. METHODS: Operative hospitalizations for ovarian cancer patients ≥65 years of age were identified using the 2010-2017 National Inpatient Sample. Admissions with high-cost were defined as those incurring ≥90th percentile of hospitalization costs each year, while the remainder were considered low-cost. Multivariable logistic regression models were developed to assess independent predictors of being in the high-cost cohort. RESULTS: During the study period, an estimated 58,454 patients met inclusion criteria. 5827 patient admissions (9.98%) were classified as high-cost. Median hospitalization cost for this high-cost group was $55,447 (interquartile range (IQR) $46,744-$74,015) compared to $16,464 (IQR $11,845-$23,286, p < 0.001) for the low-cost group. Patients with high-cost admissions were more likely to have received open (adjusted odds ratio (AOR) 2.23, 1.31-3.79) or extended (AOR 5.64, 4.79-6.66) procedures and be admitted non-electively (AOR 3.32, 2.74-4.02). Being in the top income quartile (AOR 1.77, 1.39-2.27) was also associated with high-cost. Age and hospital factors, including bed size and volume of gynecologic oncology surgery, did not affect cost group. CONCLUSION: High-cost ovarian cancer admissions were three times more expensive than low-cost admissions. Fewer open and extended procedures with subsequently shorter lengths of stay may have contributed to decreasing inpatient costs over the study period. In this cohort of patients largely covered by Medicare, clinical factors outweigh socioeconomic factors as cost drivers. Understanding the relationship of disease-specific and social factors to cost will be important in informing future value-based quality improvement efforts in gynecologic cancer care.
Assuntos
Efeitos Psicossociais da Doença , Procedimentos Cirúrgicos em Ginecologia/economia , Custos Hospitalares/estatística & dados numéricos , Neoplasias Ovarianas/economia , Idoso , Idoso de 80 Anos ou mais , Feminino , Geografia , Procedimentos Cirúrgicos em Ginecologia/métodos , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Custos Hospitalares/tendências , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Tempo de Internação/tendências , Masculino , Medicaid/economia , Medicaid/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Razão de Chances , Neoplasias Ovarianas/cirurgia , Admissão do Paciente/economia , Admissão do Paciente/estatística & dados numéricos , Melhoria de Qualidade/economia , Estudos Retrospectivos , Fatores de Risco , Estados UnidosRESUMO
The use of poly (ADP-ribose) polymerase (PARP) inhibitors in the front-line management of advanced ovarian cancer has recently emerged as an exciting strategy with the potential to improve outcomes for patients with advanced ovarian cancer. In this article, we review the results of four recently published Phase III randomised controlled trials evaluating the use of PARP inhibitors in the primary treatment of ovarian cancer (SOLO1, PRIMA, PAOLA-1, and VELIA). Collectively, the studies suggest that PARP maintenance in the upfront setting is most beneficial among patients with BRCA-associated ovarian cancers (hazard ratios range from 0.31 to 0.44), followed by patients with tumours that harbour homologous recombination deficiencies (hazard ratios range from 0.33 to 0.57). All three studies that included an all-comer population were able to demonstrate benefit of PARP inhibitors, regardless of biomarker status. The FDA has approved olaparib for front-line maintenance therapy among patients with BRCA-associated ovarian cancers, and niraparib for all patients, regardless of biomarker status. In determining which patients should be offered front-line maintenance PARP inhibitors, and which agent to use, there are multiple factors to consider, including FDA indication, dosing preference, toxicity, risks versus benefits for each patient population, and cost. There are ongoing studies further exploring the front-line use of PARP inhibitors, including the potential downstream effects of PARP-inhibitor resistance in the recurrent setting, combining PARP-inhibitors with other anti-angiogenic drugs, immunotherapeutic agents, and inhibitors of pathways implicated in PARP inhibitor resistance.