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Economic Analysis of Neoadjuvant Chemotherapy Versus Primary Debulking Surgery for Advanced Epithelial Ovarian Cancer Using an Aggressive Surgical Paradigm
  1. Ashley L. Cole, MPH*,
  2. Emma L. Barber, MD, MS,
  3. Anagha Gogate, MHS,
  4. Arthur-Quan Tran, MD and
  5. Stephanie B. Wheeler, PhD, MPH
  1. *Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy,
  2. Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and
  3. Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC.
  1. Address correspondence and reprint requests to Ashley L. Cole, MPH, Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, 2200 Kerr Hall, Campus Box 7573, University of North Carolina, Chapel Hill, NC 27599. E-mail:


Objectives Neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) for advanced epithelial ovarian cancer (AEOC) remains controversial in the United States. Generalizability of existing trial results has been criticized because of less aggressive debulking procedures than commonly used in the United States. As a result, economic evaluations using input data from these trials may not accurately reflect costs and outcomes associated with more aggressive primary surgery. Using data from an ongoing trial performing aggressive debulking, we investigated the cost-effectiveness and cost-utility of NACT versus PDS for AEOC.

Methods A decision tree model was constructed to estimate differences in short-term outcomes and costs for a hypothetical cohort of 15,000 AEOC patients (US annual incidence of AEOC) treated with NACT versus PDS over a 1-year time horizon from a Medicare payer perspective. Outcomes included costs per cancer-related death averted, life-years and quality-adjusted life-years (QALYs) gained. Base-case probabilities, costs, and utilities were based on the Surgical Complications Related to Primary or Interval Debulking in Ovarian Neoplasms trial. Base-case analyses assumed equivalent survival; threshold analysis estimated the maximum survival difference that would result in NACT being cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds. Probabilistic sensitivity analysis was used to characterize model uncertainty.

Results Compared with PDS, NACT was associated with $142 million in cost savings, 1098 fewer cancer-related deaths, and 1355 life-years and 1715 QALYs gained, making it the dominant treatment strategy for all outcomes. In sensitivity analysis, NACT remained dominant in 99.3% of simulations. Neoadjuvant chemotherapy remained cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds if survival differences were less than 2.7 and 1.4 months, respectively.

Conclusions In the short term, NACT is cost-saving with improved outcomes. However, if PDS provides a longer-term survival advantage, it may be cost-effective. Research is needed on the role of patient preferences in tradeoffs between survival and quality of life.

  • Advanced ovarian cancer
  • Cost-effectiveness analysis
  • Neoadjuvant chemotherapy

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  • A.L.C. is an employee of Truven Health Analytics, an IBM Company. A.G. held a paid internship position at Janssen Pharmaceuticals, Inc, during the time of this work. S.B.W. is the recipient of a Pfizer Independent Grant for Learning and Change. The remaining authors declare no conflicts of interest.

  • Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (