Emma S. Ryan

Cost-Effectiveness of Venous Thromboembolism Prophylaxis During Neoadjuvant Chemotherapy for Ovarian Cancer

PURPOSE: Two recent clinical trials have demonstrated that direct oral anticoagulants (DOACs) are effective as venous thromboembolism (VTE) prophylaxis in patients with moderate-to-high risk ambulatory cancer initiating chemotherapy. Patients with advanced ovarian cancer receiving neoadjuvant chemotherapy are at particularly increased risk of VTE. We performed a cost-effectiveness analysis from a health system perspective to determine if DOACs are a feasible prophylactic strategy in this population. METHODS: A simple decision tree was created from a health system perspective, comparing two strategies: prophylactic DOAC taken for 18 weeks during chemotherapy versus no VTE prophylaxis. Rates of VTE (7.3% DOAC v 13.6% no treatment), major bleeding (2.6% v 1.3%), and clinically relevant nonmajor bleeding (4.6% v 3.3%) were modeled. Cost estimates were obtained from wholesale drug costs, published studies, and Medicare reimbursement data. Probabilistic, one-way, and two-way sensitivity analyses were performed. RESULTS: In the base case model, DOAC prophylaxis is more costly and more effective than no therapy (incremental cost-effectiveness ratio = $256,218 in US dollars/quality-adjusted life year). In one-way sensitivity analyses, reducing the DOAC cost by 32% or raising the baseline VTE rate above 18% renders this strategy potentially cost-effective with an incremental cost-effectiveness ratio below $150,000 in US dollars/quality-adjusted life year. CONCLUSION: Further confirmation of the true baseline VTE rate among women initiating neoadjuvant chemotherapy for ovarian cancer will determine whether prophylactic dose DOAC is a value-based strategy. Less costly VTE prophylaxis options such as generic DOACs (once available) and aspirin also warrant investigation.

Preferences of BRCA mutation carriers for attributes of risk‐reducing surgical options for breast and ovarian cancer

Abstract Background Risk‐reducing surgeries are the most effective strategies for cancer prevention in patients with germline pathogenic variants in the BRCA1 / BRCA2 genes; these surgeries are associated with early menopause, loss of childbearing potential, and cosmetic effects. The authors assessed women's preferences for tradeoffs related to risk‐reducing surgical decision making. Methods Carriers of pathogenic mutations in BRCA1/BRCA2 aged 25–50 years without a personal history of breast, ovarian, peritoneal, or tubal cancer were recruited to complete one of four discrete choice surveys based on their age (younger than 40 years or 40 years and older) and BRCA mutation status (BRCA1 or BRCA2). Participants responded to a series of choices between a do‐nothing strategy and two profiles representing various effects of surgical options on menopause, childbearing potential (those younger than 40 years only), breast appearance, and 10‐year and lifetime risks of breast and ovarian cancer. A conditional logit model was used to quantify participants' choices as a function of surgical options and outcomes. Results In total, 298 participants completed the survey. Each cohort younger than <40 years more frequently chose profiles representing risk‐reducing salpingo‐oophorectomy (RRSO) at age 40 versus 30 years. The cohort aged 40 years and older with BRCA1 mutations favored RRSO at age 40 years but with a 56.6% choice probability of delayed RRSO after ages 35–40 years, as recommended by National Comprehensive Cancer Network guidelines. The cohort aged 40 and older with BRCA2 mutations favored RRSO at age 40, 45, or 50 years fairly equally, with a 33.0% choice probability of guideline‐nonconcordant RRSO timing. All cohorts favored mastectomy at younger ages and with reconstruction versus no mastectomy. Conclusions These findings demonstrate the heterogeneity of preferences and support individualized discussion of treatment goals relating to risk‐reducing surgical planning.