Cost-Effectiveness of Direct Oral Anticoagulants for VTE Prophylaxis in Ovarian Cancer

Venous thromboembolism (VTE) prophylaxis with direct oral anticoagulants during neoadjuvant chemotherapy for ovarian cancer is more costly but more effective than no therapy, according to a recent cost-effectiveness analysis (JCO Oncol Pract. 2021 Apr 29;OP2000783. doi: 10.1200/OP.20.00783).

Recent trials have revealed that direct oral anticoagulants are effective as VTE prophylaxis in patients with moderate-to-high risk ambulatory cancer initiating chemotherapy, however, these trials did not analyze the cost-effectiveness.

“Patients with advanced ovarian cancer receiving neoadjuvant chemotherapy are at particularly increased risk of [VTE]” wrote Emma Ryan, BS, Duke University School of Medicine, Durham, NC, and colleagues, adding, “We performed a cost-effectiveness analysis from a health system perspective to determine if direct oral anticoagulants are a feasible prophylactic strategy in this population.”

Dr Ryan and colleagues compared prophylactic direct oral anticoagulants for 18 weeks during chemotherapy vs no VTE prophylaxis using a simple decision tree created from a health perspective system.  Rates of VTE (7.3% direct oral anticoagulants v 13.6% no treatment), major bleeding (2.6% v 1.3%), and clinically relevant nonmajor bleeding (4.6% v 3.3%) were modeled.

Data from published studies, wholesale drug costs, and Medicare reimbursement were used to estimate costs. Probabilistic, one-way, and two-way sensitivity analyses were performed.

Results from the base case model suggested that direct oral anticoagulants prophylaxis is more costly and more effective than no therapy, with an incremental cost-effectiveness ratio of $256,218 per quality-adjusted life year (QALY).

The one-way sensitivity analyses revealed that in order to be considered cost-effective, either the direct oral anticoagulant costs would need to be reduced by 32%, or the baseline VTE rate would need to raise above 18%, resulting in an incremental cost-effectiveness ratio below $150,000 per QALY.

“Further confirmation of the true baseline [VTE] rate among women initiating neoadjuvant chemotherapy for ovarian cancer will determine whether prophylactic dose direct oral anticoagulants is a value-based strategy” concluded Dr Ryan and colleagues, adding, “Less costly [VTE] prophylaxis options such as generic direct oral anticoagulants (once available) and aspirin also warrant investigation.”—Marta Rybczynski