Cost-Effectiveness of BRCA1 and BRCA2 Mutation Testing to Target PARP Inhibitor Use in Platinum-Sensitive Recurrent Ovarian Cancer.

Secord AA, Barnett JC, Ledermann JA, Peterson BL, Myers ER, Havrilesky LJ.

Source

*Division of Gynecologic Oncology, Duke Cancer Institute, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC; †Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brooke Army Medical Center, Fort Sam Houston, TX; ‡UCL Cancer Institute and Biomedical Research Centre, London, United Kingdom; §Department of Biostatistics and Bioinformatics, and ∥Division of Clinical and Epidemiological Research, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.

Abstract

OBJECTIVES:

(1) To determine whether use of a PARP inhibitor or (2) BRCA1/2 mutation testing followed by a PARP inhibitor for test positives is potentially cost-effective for maintenance treatment of platinum-sensitive recurrent high-grade serous ovarian cancer.

METHODS:

A modified Markov decision analysis compared 3 strategies: (1) observe; (2) olaparib to progression; (3) BRCA1/2 mutation testing; treat mutation carriers with olaparib to progression. Progression-free survival and rates of adverse events were derived from a phase 2 randomized trial. Key assumptions are as follows: (1) 14% of patients harbor a BRCA1/2 mutation; (2) progression-free survival of individuals treated with olaparib is improved for BCRA1/2 carriers compared with noncarriers (estimated hazard ratio, approximately 0.4). Costs derived from national data were assigned to treatments, adverse events, and BRCA1/2 test. Monte Carlo probabilistic sensitivity analysis was performed.

RESULTS:

Global olaparib was the most effective strategy, followed by BRCA1/2 testing and no olaparib. BRCA1/2 testing had an incremental cost-effectiveness ratio (ICER) of $193,442 per progression-free year of life saved (PF-YLS) compared to no olaparib, whereas global olaparib had an ICER of $234,128 per PF-YLS compared to BRCA1/2 testing. At a 52% lower-than-baseline olaparib cost estimate of $3000 per month, BRCA1/2 testing became potentially cost-effective compared with observation, with an ICER of $100,000 per PF-YLS. When strategy (1) was removed from the analysis, BRCA1/2 testing was the preferred strategy.

CONCLUSIONS:

The use of maintenance olaparib in women with high-grade serous ovarian cancer is not cost-effective regardless of whether BRCA1/2 testing is used to direct treatment. However, BRCA1/2 testing is a preferred strategy compared to global maintenance olaparib alone.