UC Irvine

Background: The greatest clinical obstacle in advanced ovarian cancer remains acquired drug resistance, indicative of the absence of effective maintenance therapies. We evaluated cost-effectiveness of available maintenance strategies for advanced ovarian cancer, adjusting for pre-treatment medication costs, infusion center charges, and costs of managing adverse events.

Methods: Toxicity and median PFS data were attained from the registration trials for a) paclitaxel (GOG 212); b) bevacizumab (GOG 218, ICON 7, OCEANS, GOG 213); c) niraparib (NOVA), olaparib (SOLO-2), rucaparib (ARIEL-3), and d) pembrolizumab. Since bevacizumab was investigated in different patient populations, each trial was modeled separately. Checkpoint inhibition phase III randomized trials in ovarian cancer are not mature, thus data for pembrolizumab (available via agnostic indication) was obtained from the phase IB ovarian cohort of KEYNOTE-028. Utilizing a Markov model, patients transitioned through health states of response, hematological and non-hematological complications, progression, and death. Using Medicare data, the costs of pretreatment testing, infusions, and managing toxicities were estimated. To compare the therapies, incremental cost-effectiveness ratios (ICER) and quality of adjusted life-months gained were calculated.

Results: Seemingly, the most cost-effective was maintenance paclitaxel at $1,329 /PFS month. Expected costs of PARP inhibitors (PARPi(s)) prior to progression were approx. $510,387 (20.3x paclitaxel, 7.5x pembrolizumab, and 2.6-3.2x bevacizumab). Comparing pembrolizumab to PARPi(s) in BRCA-deficient patients, the immunotherapy maintenance therapy generated ICERs per month of life gained of $23,055 (niraparib), $25,622 (rucaparib), and $28,465 (olaparib).

Conclusion: Employing PFS as the benchmark, high costs of maintenance PARPi(s) are not abated by adjusting for the sequelae that occurs with maintenance chemotherapy and anti-angiogenic therapy. The current trend to study novel combinations is challenging when considering economic toxicity and the burden it places on our patients.