Journal
CANCER
Volume 126, Issue 8, Pages 1736-1748Publisher
WILEY
DOI: 10.1002/cncr.32724
Keywords
apixaban; cost-benefit analysis; factor Xa inhibitors; neoplasm; rivaroxaban; venous thromboembolism
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Funding
- Conquer Cancer Foundation Young Investigator Award
- Hemostasis and Thrombosis Research Society Mentored Research Award - independent medical educational grant from Shire
- National Hemophilia Foundation Shire Clinical Fellowship Award
- Sondra and Stephen Hardis Chair in Oncology Research at the Taussig Cancer Institute at Cleveland Clinic
- Consortium Linking Oncology with Thrombosis (CLOT) of the National Heart, Lung, and Blood Institute [U01-HL143402]
- T2 Research Chair in Venous Thromboembolism and Cancer from the Department of Medicine at the University of Ottawa
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Background Randomized controlled trials (RCTs) have demonstrated that low-dose direct oral anticoagulants (DOACs), including rivaroxaban and apixaban, may help reduce the incidence of cancer-associated venous thromboembolism (VTE). Methods A cost-utility analysis was performed from the health sector perspective using a Markov state-transition model in patients with cancer who are at intermediate-to-high risk for VTE. Transition probability, relative risk, cost, and utility inputs were obtained from a meta-analysis of the RCTs and relevant epidemiology studies. Differences in cost, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER) per patient were calculated over a lifetime horizon. One-way, probabilistic, and scenario sensitivity analyses were conducted. Results In patients with cancer at intermediate-to-high risk for VTE, treatment with low-dose DOAC thromboprophylaxis for 6 months, compared with placebo, was associated with 32 per 1000 fewer VTE and 11 per 1000 more major bleeding episodes over a lifetime. The incremental cost and QALY increases were $1445 and 0.12, respectively, with an ICER of $11,947 per QALY gained. Key drivers of ICER variations included the relative risks of VTE and bleeding as well as drug cost. This strategy was 94% cost effective at the threshold of $50,000 per QALY. The selection of patients with Khorana scores >= 3 yielded the greatest value, with an ICER of $5794 per QALY gained. Conclusions Low-dose DOAC thromboprophylaxis for 6 months appears to be cost-effective in patients with cancer who are at intermediate-to-high risk for VTE. The implementation of this strategy in patients with Khorana scores >= 3 may lead to the highest cost-benefit ratio.
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