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Cost-effectiveness of management strategies for patients with recurrent ovarian cancer and inoperable malignant bowel obstruction

  • Pamela N. Peters
    Correspondence
    Corresponding author at: 200 Trent Drive, Baker House 243, Durham, NC 27710, United States.
    Affiliations
    Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, 200 Trent Drive, Baker House 243, Durham, NC 27710, United States

    Duke University Health System and The Duke Cancer Institute, 2 Seeley Mudd, 10 Bryan Searle Drive, Durham, NC 27710, United States
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  • Julia M. Moyett
    Affiliations
    Duke University School of Medicine, 40 Duke Medicine Circle, 124 Davison Building, Durham, NC 27710, United States
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  • Brittany A. Davidson
    Affiliations
    Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, 200 Trent Drive, Baker House 243, Durham, NC 27710, United States

    Duke University Health System and The Duke Cancer Institute, 2 Seeley Mudd, 10 Bryan Searle Drive, Durham, NC 27710, United States
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  • Sarah Cantrell
    Affiliations
    Duke University Medical Center Library & Archives, Seeley G. Mudd Bldg, 103, Durham, NC 27710, United States
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  • Sara E. Bliss
    Affiliations
    Duke Department of Pharmacy, 40 Duke Medicine Circle First floor, Red Zone, Room 1822, Durham, NC 27710, United States
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  • Laura J. Havrilesky
    Affiliations
    Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, 200 Trent Drive, Baker House 243, Durham, NC 27710, United States

    Duke University Health System and The Duke Cancer Institute, 2 Seeley Mudd, 10 Bryan Searle Drive, Durham, NC 27710, United States
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Published:November 04, 2022DOI:https://doi.org/10.1016/j.ygyno.2022.10.013

      Highlights

      • Parenteral nutrition is not cost-effective management of recurrent ovarian cancer & inoperable malignant bowel obstruction.
      • Hospice is an appropriate strategy for patients with recurrent ovarian cancer & inoperable malignant bowel obstruction.
      • Goals of care, quality of life, survival, and cost should be considered when making clinical decisions in this setting.

      Abstract

      Objectives

      Patients with recurrent platinum-resistant ovarian cancer often present with inoperable malignant bowel obstruction (MBO) from a large burden of abdominal disease. Interventions such as total parenteral nutrition (TPN) and chemotherapy may be used in this setting. We aim to describe the relative cost-effectiveness of these interventions to inform clinical decision making.

      Methods

      Four strategies for management of platinum-resistant recurrent ovarian cancer with inoperable MBO were compared from a societal perspective using a Monte Carlo simulation: (1) hospice, (2) TPN, (3) chemotherapy, and (4) TPN + chemotherapy. Survival, hospitalization rates, end-of-life (EOL) setting, and MBO-related utilities were obtained from literature review: hospice (survival 38 days, 6% hospitalization), chemotherapy (42 days, 29%), TPN (55 days, 25%), TPN + chemotherapy (74 days, 47%). Outcomes were the average cost per strategy and incremental cost-effectiveness ratios (ICERs) in US dollars per quality-adjusted life year (QALY) gained.

      Results

      In the base case scenario, TPN + chemotherapy was the most costly strategy (mean; 95% CI) ($49,741; $49,329–$50,162) and provided the highest QALYs (0.089; 0.089–0.090). The lowest cost strategy was hospice ($14,591; $14,527–$14,654). The TPN alone and chemotherapy alone strategies were dominated by a combination of hospice and TPN + chemotherapy. The ICER of TPN + chemotherapy was $918,538/QALY compared to hospice. With a societal willingness to pay threshold of $150,000/QALY, hospice was the strategy of choice in 71.6% of cases, chemotherapy alone in 28.4%, and TPN-containing strategies in 0%.

      Conclusions

      TPN with or without chemotherapy is not cost-effective in management of inoperable malignant bowel obstruction and platinum-resistant ovarian cancer.

      Keywords

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