Aggressive and complex surgery for advanced ovarian cancer : an economic analysis

Introduction: In an initial cohort we demonstrated that aggressive surgery correlates with improved survival in patients with advanced ovarian cancer yet the economic implications of maximal surgical efforts are unknown. Objective: To evaluate inpatient costs, survival, and cost-effectiveness of alternative primary surgical approaches among advanced ovarian cancer patients. Methods: All patients with a diagnosis of stage IIIC-IV ovarian cancer between 1994 and 2003 were identified and classified by surgical complexity score (SCS) (1 = simple, 2 = intermediate, and 3 = complex). We used clinical and administrative data to estimate costs associated with inpatient stay, survival, and the 5-year cost-effectiveness of complex vs. simple surgery measured in costs per life-year gained. Results: 486 consecutive patients were identified of whom 28%, 50%, and 22% were classified as SCS 1, 2, and 3, respectively. Kaplan-Meier estimated survival differed by SCS group (p < 0.001) with an average survival gain of 1.32 years with complex vs. simple surgery (SCS group 3 vs. 1). Inpatient costs significantly differed between SCS groups (mean costs SCS 1: $21,914; SCS 2: $27,408; SCS 3: $33,678; p < 0.001). Analyses suggest incremental cost-effectiveness ratios of $4950 and $8912 per life-year gained, comparing SCS groups 2 vs. 1 and 3 vs. 1 respectively. Conclusions: Complex surgery for ovarian cancer cytoreduction carries a survival benefit at increased direct medical cost. However, preliminary cost-effectiveness results suggest complex surgery provides good value for money spent. Future research on the cost and quality of life implications of surgical morbidity during follow-up is warranted to formally assess the cost-effectiveness of complex vs. simple surgical procedures.