Palliative Care Cost-Effective for Platinum-Resistant Ovarian Cancer

Charles Bankhead

May 2013, Vol 4, No 4 - Economics of Cancer Care

Los Angeles, CA—Early palliative care proved to be cost-effective and cost-saving versus routine end-of-life care for patients with recurrent platinum-resistant ovarian cancer, according to a decision-model analysis.

Based on a 6-month time horizon, the model projected a savings of $1275 per patient versus routine care. In a 1-way sensitivity analysis, palliative care remained within an incremental cost-effectiveness ratio (ICER) of $50,000 per quality-adjusted life-year (QALY), until the cost of the intervention exceeded $2400—approximately $2000 more than the estimated cost.

“When we assumed no clinical benefit of early palliative care other than quality of life, early palliative care remained highly cost-effective, with an incremental cost-effectiveness ratio of $37,440 per quality-adjusted life-year,” William J. Lowery, MD, Fellow, Division of Gynecologic Oncology, Department of Obstetrics and Gy­necology, Duke University, Durham, NC, and colleagues reported at the 2013 Society of Gynecologic Oncology annual meeting.

Sensitivity analyses incorporating a variety of clinical and cost parameters showed no significant changes in the model’s basic findings.
The background for this analysis came from a randomized controlled trial involving patients with meta­static non–small-cell lung cancer (NSCLC). Early palliative care was associated with fewer hospital admissions and fewer emergency department visits, as well as reduced administration of chemotherapy in the last 30 days of life (Temel JS, et al. N Engl J Med. 2010;363:733-742).

Applying the underlying principles of the lung cancer study to recurrent ovarian cancer, Dr Lowery and colleagues constructed a decision model to compare the cost of routine end-of-life care (determined by the treating physician) with the cost of routine care plus early palliative care. They defined the intervention as monthly consultation with a palliative care provider to discuss symptoms and the goals of care and to assist with decision-making that is related to proposed treatment.

The primary outcome was the average cost of each treatment strategy. The investigators used the NSCLC study to develop the decision model for recurrent ovarian cancer. The key assumptions were:

  • Each patient who was hospitalized was assumed to have a single hospitalization
  • Patients who visited emergency departments were assumed to have done so once
  • Liposomal doxorubicin was the chemotherapy regimen for all patients
  • Patients who received early palliative care had an initial outpatient visit, followed by 5 monthly visits
  • The base model did not include quality of life
  • Survival was equivalent with the 2 strategies.

Results of the NSCLC trial showed that early palliative care was associated with a 32% odds ratio for hospital admission, a 26% reduction in the odds ratio for emergency department visits, and a 23% reduction in the odds ratio for chemotherapy administration. These outcomes were incorporated into the decision model for recurrent platinum-resistant ovarian cancer.

The costs (including hospital admission, emergency department visits, chemotherapy administration, and palliative care) were obtained from the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services. The estimated cost of early palliative care was $472 per case.

The model produced a base case with an average cost of $5017 for early palliative care and $6303 for routine care alone, a savings of $1286 per patient. In a sensitivity analysis incorporating quality of life, the strategy of early palliative care remained dominant compared with routine care, Dr Lowery and colleagues reported.

Sensitivity analyses showed that early palliative care would have to cost more than $3000 before the ICER exceeded $100,000 per QALY versus routine care.

Invited discussant Amer Karam, MD, a gynecologic and surgical oncologist, Department of Obstetrics and Gynecology, University of California, Los Angeles Health System, found several aspects of the analysis open to questioning, beginning with the applicability of data derived from a study of metastatic NSCLC to platinum-resistant recurrent ovarian cancer.

He also cited limitations related to the thresholds used to define cost-effectiveness and to the assumption that early palliative care would incur no additional costs beyond the $472 over 6 months.