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

Secord, Angeles Alvarez MD, MHSc*; Barnett, Jason Cory MD; Ledermann, Jonathan A. MD; Peterson, Bercedis L. PhD, MS§; Myers, Evan R. MD, MPH; Havrilesky, Laura J. MD, MHSc*

International Journal of Gynecological Cancer: June 2013 - Volume 23 - Issue 5 - p 846–852
doi: 10.1097/IGC.0b013e31829527bd
Ovarian Cancer

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.

*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.

Address correspondence and reprint requests to Angeles Alvarez Secord, MD, MHSc, DUMC 3079, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27710. E-mail: secor002@mc.duke.edu.

The authors declare no conflicts of interest.

Received February 5, 2013

Accepted April 2, 2013

Copyright © 2013 by IGCS and ESGO