Hysterectomy versus chemotherapy for low-risk non-metastatic gestational trophoblastic neoplasia (GTN): A cost-effectiveness analysis

• Published in: Gynecologic oncology 2024-08, Vol.187, p.30-36
• Main Authors: Mitric, Cristina, Sayyid, Rashid K., Fleshner, Neil E., Look Hong, Nicole J., Bouchard-Fortier, Genevieve
• Format: Article
• Language: English
• Subjects: Adult; Antineoplastic Combined Chemotherapy Protocols - economics; Antineoplastic Combined Chemotherapy Protocols - therapeutic use; Canada; Cost-Benefit Analysis; Cost-effectiveness; Cost-Effectiveness Analysis; Cost-utility; Cyclophosphamide - administration & dosage; Cyclophosphamide - economics; Cyclophosphamide - therapeutic use; Dactinomycin - administration & dosage; Dactinomycin - economics; Dactinomycin - therapeutic use; Decision Support Techniques; Female; Gestational Trophoblastic Disease - drug therapy; Gestational Trophoblastic Disease - economics; Gestational Trophoblastic Disease - surgery; Gestational trophoblastic neoplasia; Humans; Hysterectomy; Hysterectomy - economics; Markov Chains; Methotrexate - administration & dosage; Methotrexate - economics; Methotrexate - therapeutic use; Pregnancy; QALY; Quality-Adjusted Life Years
• ISSN: 0090-8258; 1095-6859; 1095-6859
• DOI: 10.1016/j.ygyno.2024.04.014

Determine the cost-effectiveness for hysterectomy versus standard of care single agent chemotherapy for low-risk gestational trophoblastic neoplasia (GTN). A cost-effectiveness analysis was conducted comparing single agent chemotherapy with hysterectomy using decision analysis and Markov modeling from a healthcare payer perspective in Canada. The base case was a 40-year-old patient with low-risk non-metastatic GTN that completed childbearing. Outcomes were life years (LYs), quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICER), and adjusted 2022 costs (CAD). Discounting was 1.5% annually and the time horizon was the patient's lifetime. Model validation included face validity, deterministic sensitivity analyses, and scenario analysis. Mean costs for chemotherapy and hysterectomy arms were $34,507 and $17,363, respectively, while effectiveness measure were 30.37 QALYs and 31.04 LYs versus 30.14 QALYs and 30.82 Lys, respectively. The ICER was $74,526 (USD $54,516) per QALY. Thresholds favoring hysterectomy effectiveness were 30-day hysterectomy mortality below 0.2% and recurrence risk during surveillance above 9.2% (low-risk) and 33.4% (high-risk). Scenario analyses for Dactinomycin and Methotrexate led to similar results. Sensitivity analysis using tornado analysis found the cost to be most influenced by single agent chemotherapy cost and risk of resistance, number of weeks of chemotherapy, and probability of postoperative mortality. Compared to hysterectomy, single agent chemotherapy as a first-line treatment costs $74,526 for each additional QALY gained. Given that this cost falls below the accepted $100,000 willingness-to-pay threshold and waitlist limitations within public healthcare systems, these results support the continued use of chemotherapy as standard of care approach for low-risk GTN. •Single agent chemotherapy for low-risk GTN has higher costs and higher effectiveness compared to hysterectomy.•There is an additional cost of $74,526 CAD ($54,516 USD) for each additional QALY achieved with chemotherapy.•Single agent chemotherapy cost, risk of resistance, and chemotherapy duration are key factors impacting treatment costs.