Maximizing Value and Quality in Gynecologic Cancer Care—Work in Progress

Wayne Kuznar

September 2014, Vol 5, No 7 - Value in Oncology


Chicago, IL—Comparative effectiveness research (CER) and cost-effectiveness analyses have helped to define value as it relates to gynecologic oncology, said speakers during an education session on maximizing value and quality in gynecologic cancer care, at the 2014 American Society of Clinical Oncology meeting.

The rising cost of healthcare has forced an examination of value. Value is defined as desirable health outcomes achieved per monetary unit spent, suggested Laura J. Havrilesky, MD, MHSc, Associate Professor of Obstetrics and Gynecology at Duke University Medical Center, Durham, NC.

Although CER is being used to determine value in cancer care, the cost of the therapies being compared in such studies is rarely considered, because of research funding restrictions, Dr Havrilesky said.

By contrast, a cost-effectiveness analysis compares the cost and effectiveness of 2 current therapies, adding an essential component to value measurement.

Implications of Cost-Effectiveness Analyses for Cancer Care
In oncology, the measure of cost-effectiveness is usually related to patient overall survival (OS), which is expressed as a dollar amount per quality-adjusted life-year (QALY) gained.

“Drug cost is critical,” said Dr Havrilesky. “Targeted therapies may be more cost-effective than global treatment with expensive therapeutics.”

In ovarian cancer, “testing to select individuals likely to benefit from targeted interventions is potentially cost-effective when compared with global treatment,” Dr Havrilesky said.

Intraperitoneal chemotherapy for ovarian cancer has risen to the level of standard therapy based on improvement in OS compared with intra­venous chemotherapy and an in­cremental cost-effectiveness ratio of ‹ $40,000 per QALY gained, which is well within the limit that is accepted as cost-effective.

Although adding bevacizumab (Avastin) to a standard chemotherapy regimen can improve progression-free survival by several months, the incremental cost-effectiveness ratio exceeds $400,000 per 1 year of progression-free survival, she noted. The cost of beva­cizumab would have to decline to 25% of its current reimbursement to be cost-effective in this setting.

A predictive test to determine treatment with bevacizumab could possibly improve its cost-effectiveness, with an incremental cost-effectiveness ratio of approximately $130,000 per QALY. Until then, high-profile biologic agents do not appear to meet the standard societal willingness-to-pay thresholds.

Gynecologic oncologists must consider the possible toxicity level and the inconvenience of added treatments and the potential additional out-of-pocket expenses when considering adding novel therapies to the treatment regimen, deciding for or against maintenance chemotherapy, assigning treatment for recurrent disease, and when making the decision to move a patient to end-of-life care, Dr Havril­esky pointed out.

Guideline-Based Care Improves Survival
William A. Cliby, MD, Professor of Obstetrics and Gynecology at the Mayo Clinic, Rochester, MN, presented the evidence-based measures of quality in gynecologic surgery, again using ovarian cancer as an example. Overall, the cancer care delivery system in the United States is in crisis, he said, because cancer care is often not as patient-centered, accessible, coordinated, or evidence-based as it could be.

Adherence to National Comprehensive Cancer Network (NCCN) guideline care is a reasonable outcome measure. Following NCCN guidelines in surgical staging and in selecting chemotherapy regimens improves survival in patients with ovarian cancer.

However, “most patients don’t receive guideline care,” said Dr Cliby. “The application of existing best practices is the most cost-effective form of quality improvement.”

Case volume and guideline care have been shown to be important drivers of survival in this disease, but 25% of patients with ovarian cancer are treated across 65% of centers, all with fewer than 8 cases per center. Similar themes are observed with the care of patients with cervical cancer, he noted.