Duke University School of Medicine, Durham, NC.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
JCO Oncol Pract. 2021 Aug;17(8):e1075-e1084. doi: 10.1200/OP.20.00783. Epub 2021 Apr 29.
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.
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 13.6% no treatment), major bleeding (2.6% 1.3%), and clinically relevant nonmajor bleeding (4.6% 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.
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.
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.
两项最近的临床试验表明，直接口服抗凝剂（DOAC）在接受中高危门诊癌症化疗的患者中预防静脉血栓栓塞症（VTE）是有效的。接受新辅助化疗的晚期卵巢癌患者 VTE 风险特别增加。我们从卫生系统的角度进行了成本效益分析，以确定 DOAC 是否是该人群可行的预防策略。
从卫生系统的角度创建了一个简单的决策树，比较了两种策略：化疗期间预防性使用 DOAC 18 周与不进行 VTE 预防。VTE（DOAC 组 7.3%，无治疗组 13.6%）、大出血（2.6%，1.3%）和临床相关非大出血（4.6%，3.3%）的发生率进行建模。成本估算来自批发药品成本、已发表的研究和医疗保险报销数据。进行了概率、单向和双向敏感性分析。
在基本模型中，DOAC 预防比不治疗更昂贵且更有效（增量成本效益比为 256218 美元/质量调整生命年）。在单向敏感性分析中，将 DOAC 成本降低 32%或将基线 VTE 率提高到 18%以上，将使该策略具有成本效益，增量成本效益比低于 150000 美元/质量调整生命年。
进一步证实新辅助化疗开始时卵巢癌女性的真实基线 VTE 率将确定预防性剂量 DOAC 是否是基于价值的策略。成本更低的 VTE 预防选择，如仿制药 DOAC（一旦可用）和阿司匹林，也值得研究。
