Cost-utility Comparison of Neoadjuvant Chemotherapy Versus Primary Debulking Surgery for Treatment of Advanced Stage Ovarian Cancer in Patients ≥ 65 Years Old

OBJECTIVE: Treatment for advanced stage epithelial ovarian cancer (AEOC) includes primary debulking surgery (PDS) or neoadjuvant chemotherapy (NACT). A randomized controlled trial (RCT) comparing these treatments resulted in comparable overall survival (OS). Studies report more complications and lower chemotherapy completion rates in patients ≥65 receiving PDS. We sought to evaluate the cost implications of NACT relative to PDS in AEOC patients ≥65. STUDY DESIGN: 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, 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 (DRG) costs weighted by composite estimates of complication rates. Sensitivity analyses were performed. RESULTS: Assuming equal survival, NACT produces a cost savings of $5,616. If PDS improved median OS by ≥1.5 months, PDS would be cost-effective (CE) at a $100,000/Quality Adjusted Life Year (QALY) threshold. If PDS improved OS by ≥3.2 months it would be CE at a $50,000 threshold. The model was robust to variation in costs and complication rates. Moderate decreases in 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 to PDS for AEOC in patients ≥65. Small increases in OS with PDS or moderate declines in QOL with NACT would result in PDS being CE at the $100,000/QALY threshold. Our results support further evaluation of the effects of PDS on OS, QOL and complications in AEOC patients ≥65.