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Original research
Prophylactic anticoagulation after minimally invasive hysterectomy for endometrial cancer: a cost-effectiveness analysis
  1. Sarah Bell1,
  2. Taylor Orellana1,
  3. Alison Garrett1,
  4. Kenneth Smith2,
  5. Haeyon Kim3,
  6. Abigail Rosiello4,
  7. Shannon Rush1,
  8. Jessica Berger1 and
  9. Jamie Lesnock1
  1. 1Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  2. 2Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  3. 3Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  4. 4Howard Hughes Medical Institute - West Virginia University School of Medicine, Morgantown, West Virginia, USA
  1. Correspondence to Dr Sarah Bell, Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; bellsg{at}upmc.edu

Abstract

Objective To determine our institutional rate of venous thromboembolism (VTE) following minimally invasive surgery for endometrial cancer and to perform a cost-effectiveness analysis of extended prophylactic anticoagulation after minimally invasive staging surgery for endometrial cancer.

Methods All patients with newly diagnosed endometrial cancer who underwent minimally invasive staging surgery from January 1, 2017 to December 31, 2020 were identified retrospectively, and clinicopathologic and outcome data were obtained through chart review. Event probabilities and utility decrements were obtained through published clinical data and literature review. A decision model was created to compare 28 days of no post-operative pharmacologic prophylaxis, prophylactic enoxaparin, and prophylactic apixaban. Outcomes included no complications, deep vein thrombosis (DVT), pulmonary embolism, clinically relevant non-major bleeding, and major bleeding. We assumed a willingness-to-pay threshold of $100 000 per quality-adjusted life year (QALY) gained.

Results Three of 844 patients (0.36%) had a VTE following minimally invasive staging surgery for endometrial cancer. In this model, no pharmacologic prophylaxis was less costly and more effective than prophylactic apixaban and prophylactic enoxaparin over all parameters examined. When all patients were assigned prophylaxis, prophylactic apixaban was both less costly and more effective than prophylactic enoxaparin. If the risk of DVT was ≥4.8%, prophylactic apixaban was favored over no pharmacologic prophylaxis. On Monte Carlo probabilistic sensitivity analysis for the base case scenario, no pharmacologic prophylaxis was favored in 41.1% of iterations at a willingness-to-pay threshold of $100 000 per QALY.

Conclusions In this cost-effectiveness model, no extended pharmacologic anticoagulation was superior to extended prophylactic enoxaparin and apixaban in clinically early-stage endometrial cancer patients undergoing minimally invasive surgery. This model supports use of prophylactic apixaban for 7 days post-operatively in select patients when the risk of DVT is 4.8% or higher.

  • Venous thromboembolism
  • anti-coagulation
  • minimally invasive surgery
  • endometrial cancer

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

https://doi.org/10.1136/ijgc-2023-004922

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • Twitter @sarahgracebell

    • Contributors SB: made a substantial contribution to conception and hypothesis generation for this project and was responsible for data acquisition, data analysis, table and figure preparation, and manuscript writing. SB is the guarantor of the manuscript. TO: contributed to the conception and hypothesis generation, study design, and critical evaluation of tables, figures, and manuscript writing. AG: contributed the retrospective review of venous thromboembolism rate at our institution. KS: contributed to study design and critical evaluation of manuscript writing. HK: contributed to study design and critical evaluation of manuscript writing. AR: contributed to data acquisition. JB: contributed to study design and critical evaluation of manuscript writing. SR: contributed to critical evaluation of tables, figures, and manuscript writing. JLL: responsible for conception of the project, study design, and critical evaluation of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.