Anticoagulation in ambulatory cancer patients with no indication for prophylactic or therapeutic anticoagulation: A cost-effectiveness analysis from a U.S. perspective
Thrombosis and Haemostasis, 08/02/2012
Pishko AM et al. – Prophylactic low–molecular–weight–heparin (LMWH) given to decrease cancer–related mortality, with no conventional indication, appears economically reasonable if its suggested mortality benefit is confirmed in future trials.Methods
- Venous thromboembolism (VTE) occurs frequently in cancer patients and is a major cause of mortality.
- Although anticoagulation (AC) may have anti–tumour effects, it is recommended in cancer patients only for indications unrelated to these effects.
- A Markov model was constructed to estimate when prophylactic AC, given during four months of chemotherapy following a new cancer diagnosis, would be economically reasonable in ambulatory cancer patients with no VTE history.
- Risks and costs of major and minor bleeding, VTE, and death were obtained from the literature, including a 2011 Cochrane review of AC in cancer inpatients with no conventional indication.
- In the model, AC was low–molecular–weight–heparin (LMWH), and effects were modeled over a 24–month period.
- Model outputs were quality–adjusted life years (QALY) and the incremental cost–effectiveness ratio (ICER).
- In the base case analysis, when prophylactic AC had a two–year relative mortality risk of 0.92, there was a gain of 0.0354 QALY, for an ICER of $90,893/QALY gained, compared with no AC.
- In sensitivity analyses, AC prophylaxis cost less than $100,000/QALY, if two–year mortality exceeded 75%, or if AC costs were less than $1,076 per month, or if LMWH relative mortality risk was less than 0.927.
- Results were not sensitive to variation in VTE relative risk on AC, nor to major or minor bleeding risk on AC.
- A probabilistic sensitivity analysis also favoured prophylactic AC.