Cost Effectiveness of Chemotherapeutic Agents and Targeted Biologics in Ovarian Cancer: A Systematic Review

Insiya B. Poonawalla, Rohan C. Parikh, Xianglin L. Du, Helena M. VonVille, David R. Lairson

Adjuvant chemotherapy is a key component of advanced ovarian cancer treatment, when surgery alone is not sufficient. Recurrence is common in ovarian cancer patients and most women require prolonged second-line and higher-line chemotherapy. With newer targeted therapies, modest improvements in survival and quality of life may be attained at substantial cost, but the relative economic efficiency of these newer agents remains unknown. We undertook this systematic review to comprehensively evaluate the cost-effectiveness of various chemotherapeutic and targeted therapy alternatives for ovarian cancer. We searched Medline, PubMed, and Embase databases to identify economic evaluations published over the last 18 years (1996-2014). From the 2513 unique papers retrieved, 74 full texts were selected for full-text review based on a priori eligibility criteria. Two authors independently reviewed these articles to determine eligibility for final review. The quality of the included studies was assessed using the Quality of Health Economic Studies (QHES). A total of 28 studies were included for reporting. Administration of intravenous cisplatin-paclitaxel combination chemotherapy for first-line treatment was the most cost-effective alternative (2014 US dollars [USD] equivalent incremental cost-effectiveness ratio [ICER] ~US$17,000-US$27,000 per life year gained [LYG]), while the use of bevacizumab did not demonstrate similar value for money (2014 USD equivalent ICER was greater than US$200,000 per quality-adjusted life-year [QALY]). For second-line treatment, the use of platinum-paclitaxel combination or platinum monotherapy was cost-effective compared with platinum monotherapy or best supportive care, respectively, in women with recurrent platinum-sensitive disease. For patients with partial platinum sensitivity, pegylated liposomal doxorubicin (PLD) plus trabectedin may be cost-effective (2014 USD equivalent ICER was ~US$57,000-US$62,000 per QALY) compared with PLD alone. For recurrent platinum-resistant cases, there was limited evidence to conclude the most valuable treatment; though one study showed that best supportive care was most cost-effective, while second-line monotherapy with doxorubicin (2014 USD equivalent ICER was ~US$90,000 per LYG) may also be cost-effective compared with best supportive care. Despite varying methodological approaches and multiple sources for cost and effectiveness inputs, this systematic review demonstrated that standard platinum-taxane combination chemotherapy for first-line treatment was most cost-effective. There was unanimous agreement that bevacizumab was not a cost-effective front-line therapy compared with platinum-taxane combination for the overall ovarian cancer population, though its use in the high-use population may yield better value. For second-line treatment, platinum-based chemotherapy remained cost-effective among patients with recurrent platinum-sensitive disease, while there was limited evidence to conclude the most valuable treatment alternative among patients with recurrent platinum-resistant disease. Future research incorporating real-world data is essential to corroborate findings from trial-based economic evaluations. In addition, for improving consistency in reporting and quality of studies, incorporating QALYs in this population is important, especially since chemotherapy is administered for lengthy periods of time.