Poonawalla Insiya B, Parikh Rohan C, Du Xianglin L, VonVille Helena M, Lairson David R
Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA.
Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA.
Pharmacoeconomics. 2015 Nov;33(11):1155-85. doi: 10.1007/s40273-015-0304-9.
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.
辅助化疗是晚期卵巢癌治疗的关键组成部分，尤其在单纯手术不足以治疗时。卵巢癌患者复发很常见，大多数女性需要长期接受二线及更高线的化疗。随着新型靶向治疗的出现，虽可能以高昂成本在生存和生活质量方面取得适度改善，但这些新型药物的相对经济效率仍不明确。
我们进行这项系统评价，以全面评估卵巢癌各种化疗和靶向治疗方案的成本效益。
我们检索了Medline、PubMed和Embase数据库，以识别过去18年（1996 - 2014年）发表的经济评价。从检索到的2513篇独特论文中，根据预先设定的纳入标准选择了74篇全文进行全文审查。两位作者独立审查这些文章以确定是否符合最终审查的条件。使用健康经济研究质量（QHES）评估纳入研究的质量。
共纳入28项研究进行报告。一线治疗采用静脉注射顺铂 - 紫杉醇联合化疗是最具成本效益的方案（2014年美元等效增量成本效益比[ICER]约为每获得一个生命年[LYG]17,000 - 27,000美元），而使用贝伐单抗并未显示出类似的性价比（2014年美元等效ICER大于每质量调整生命年[QALY]200,000美元）。对于二线治疗，在铂敏感复发的女性中，使用铂 - 紫杉醇联合治疗或铂单药治疗分别比铂单药治疗或最佳支持治疗更具成本效益。对于部分铂敏感的患者，与单独使用聚乙二醇化脂质体阿霉素（PLD）相比，聚乙二醇化脂质体阿霉素（PLD）加曲贝替定可能具有成本效益（2014年美元等效ICER约为每QALY 57,000 - 62,000美元）。对于铂耐药复发病例，得出最有价值治疗方案的证据有限；尽管一项研究表明最佳支持治疗最具成本效益，但与最佳支持治疗相比，阿霉素二线单药治疗（2014年美元等效ICER约为每LYG 90,000美元）也可能具有成本效益。
尽管方法学方法各异且成本和效果投入来源多样，但这项系统评价表明一线治疗采用标准铂 - 紫杉烷联合化疗最具成本效益。一致认为，对于总体卵巢癌人群，与铂 - 紫杉烷联合治疗相比，贝伐单抗不是一种具有成本效益的一线治疗方法，尽管在高使用人群中使用可能会产生更好的价值。对于二线治疗，铂类化疗在铂敏感复发患者中仍然具有成本效益，而在铂耐药复发患者中得出最有价值治疗方案的证据有限。纳入真实世界数据的未来研究对于证实基于试验的经济评价结果至关重要。此外，为提高报告的一致性和研究质量，在该人群中纳入QALY很重要，特别是因为化疗需要长期进行。
