title: Cost-utility comparison of neoadjuvant chemotherapy versus primary debulking surgery for treatment of advanced-stage ovarian cancer in patients 65 years old or older.
abstract: OBJECTIVE
  Treatment for advanced-stage epithelial ovarian cancer (AEOC) includes primary debulking surgery (PDS) or neoadjuvant chemotherapy (NACT). A randomized controlled trial comparing these treatments resulted in comparable overall survival (OS). Studies report more complications and lower chemotherapy completion rates in patients 65 years old or older receiving PDS. We sought to evaluate the cost implications of NACT relative to PDS in AEOC patients 65 years old or older.
  
  
  METHODS
  A 5 year Markov model was created. Arm 1 modeled PDS followed by 6 cycles of carboplatin and paclitaxel (CT). Arm 2 modeled 3 cycles of CT, followed by interval debulking surgery and then 3 additional cycles of CT. Parameters included OS, surgical complications, probability of treatment initiation, treatment cost, and quality of life (QOL). OS was assumed to be equal based on the findings of the international randomized control trial. Differences in surgical complexity were accounted for in base surgical cost plus add-on procedure costs weighted by occurrence rates. Hospital cost was a weighted average of diagnosis-related group costs weighted by composite estimates of complication rates. Sensitivity analyses were performed.
  
  
  RESULTS
  Assuming equal survival, NACT produces a cost savings of $5616. If PDS improved median OS by 1.5 months or longer, PDS would be cost effective (CE) at a $100,000/quality-adjusted life-year threshold. If PDS improved OS by 3.2 months or longer, it would be CE at a $50,000 threshold. The model was robust to variation in costs and complication rates. Moderate decreases in the QOL with NACT would result in PDS being CE.
  
  
  CONCLUSIONS
  A model based on the RCT comparing NACT and PDS showed NACT is a cost-saving treatment compared with PDS for AEOC in patients 65 years old or older. Small increases in OS with PDS or moderate declines in QOL with NACT would result in PDS being CE at the $100,000/quality-adjusted life-year threshold. Our results support further evaluation of the effects of PDS on OS, QOL and complications in AEOC patients 65 years old or older.
authors: Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA. Electronic address: Michelle-Rowland@ouhsc.edu.
authors: Michelle R
authors: MR
authors: Rowland
authors: Mid Atlantic Gynecologic Oncology of Mon General Hospital, Morgantown, WV.
authors: Jamie L
authors: JL
authors: Lesnock
authors: RAND Corporation, Pittsburgh, PA.
authors: Coreen
authors: C
authors: Farris
authors: Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors: Joseph L
authors: JL
authors: Kelley
authors: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Western Pennsylvania Hospital, Pittsburgh, PA.
authors: Thomas C
authors: TC
authors: Krivak
mesh_terms: D000368:Aged; D000077216:Carcinoma, Ovarian Epithelial; D017024:Chemotherapy, Adjuvant / Q000191:economics; D003362:Cost-Benefit Analysis; D065426:Cytoreduction Surgical Procedures / Q000191:economics*; D005260:Female; D006801:Humans; D020360:Neoadjuvant Therapy / Q000191:economics*; D009367:Neoplasm Staging; D009375:Neoplasms, Glandular and Epithelial / Q000191:economics* / Q000473:pathology / Q000628:therapy*; D010051:Ovarian Neoplasms / Q000191:economics* / Q000473:pathology / Q000628:therapy*
keywords: cost comparisons; neoadjuvant chemotherapy; ovarian cancer; primary debulking surgery