Costing statement: Ovarian cancer: the recognition and initial management of ovarian cancer

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1 Costing statement: Ovarian cancer: the recognition and initial management of ovarian cancer 1 Resource impact The guideline on ovarian cancer (NICE clinical guideline 122) is unlikely to have a significant cost impact for the NHS at a national level. However, expert opinion suggests that implementation of this guideline is likely to result in an increase in testing for ovarian cancer in primary care. Therefore, costs may increase for CA125 tests, ultrasound investigations and referrals to secondary care. Expert opinion recognises that it is difficult to estimate accurately this increase in activity at a national level, and so organisations should monitor expenditure in these areas locally. Expert opinion also suggests that the following benefits will offset any potential increases in the costs of testing for ovarian cancer: Some of the tests would have been done anyway, but later in the patient pathway that is, tests will be done sooner rather than later. Savings are likely to result from the earlier diagnosis of ovarian cancer. The guideline gives a more appropriate pathway of care for women with suspected ovarian cancer. This means that some women may avoid unnecessary tests such as gastrointestinal endoscopy and CT scans. There should be a reduction in incorrect referrals to other cancer specialties. Therefore it is concluded that although costs may change as a result of implementing this clinical guideline, the change is not anticipated to be significant at a national level. Organisations are advised to monitor expenditure trends in the areas described above. Costing statement: Ovarian cancer (April 2011) 1

2 The cost implications of the recommendations are discussed in section 4 to allow the calculation of any local cost impact. Organisations are therefore encouraged to assess resource impact locally. 2 Background Ovarian cancer is the leading cause of death from gynaecological cancer in the UK, and its incidence is rising. It is the fifth most common cancer in women, with a lifetime risk of about 2% in England and Wales 1. The outcome for women with ovarian cancer is generally poor, with an overall 5-year survival rate of less than 35%. This is because most women who have ovarian cancer present with advanced disease. Most women have had symptoms for months before presentation, and there are often delays between presentation and specialist referral. There is a need for greater awareness of the disease and also for initial investigations in primary and secondary care that enable earlier referral and optimum treatment. The clinical guideline does not cover the entire care pathway for ovarian cancer. It focuses on areas where there is uncertainty or wide variation in clinical practice with regard to the detection, diagnosis and initial management of ovarian cancer. The guideline recommendations are applicable to women with epithelial ovarian cancer. 3 Patient numbers affected Table 1 shows new cases of ovarian cancer registered in England in 2008 and the associated age-standardised incidence per 100,000 women. 1 See Costing statement: Ovarian cancer (April 2011) 2

3 Table 1 Ovarian cancer registrations in England 2 in 2008 Details Number of women Malignant neoplasm of ovary (OPCS-4 code C56) 5092 Rate (DASR) 3 of newly diagnosed cases per 100,000 population 15.2 Crude rate of newly diagnosed cases per 100,000 population (all ages) Table 2 shows the 2008 ovarian cancer registrations by age group. Table 2 New cases of ovarian cancer by age group Age group (years) Number diagnosed Resource impact at a local level This section provides details of costs that may be incurred as a result of initial investigations in both primary and secondary care for the detection, diagnosis and initial management of ovarian cancer. 4.1 Diagnostic tests 19.5 Table 3 summarises the unit costs for the tests recommended in the guideline. The costs are based on the NHS national tariff for New cases of cancer diagnosed in England, 2008: selected sites by age group and sex. Available at National Statistics Online: 3 DASR = directly age-standardised rate, using the European Standard Population see note 1 above. Costing statement: Ovarian cancer (April 2011) 3

4 Table 3 Unit costs Test HRG Unit cost ( ) Serum CA Alfa fetoprotein (AFP) 23 4 Beta human chorionic gonadotrophin (beta-hcg) 23 4 Ultrasound (less than 20 minutes) RA23Z 49 Ultrasound (more than 20 minutes) RA24Z 64 MRI scan RA07Z Histology DAP Cytology DAP CT scan RA12Z Retroperitoneal lymph node dissection LB45Z 3975 Retroperitoneal lymph node assessment (upper genital tract major procedures without malignancy with complications) Retroperitoneal lymph node assessment (upper genital tract major procedures without malignancy without complications) MA07A 2856 MA07B 2685 Abbreviations: HRG, Healthcare Resource Group; MRI, magnetic resonance imaging; CT, computerised tomography; CC, complications and comorbidities Detection in primary care (recommendations , , , and There is likely to be an increase in the number of women presenting at GP surgeries who will require a CA125 test, and subsequently an increase in the number of ultrasound scans for women whose serum CA125 is 35 IU/ml or greater. However, it is difficult to estimate how many more women will be tested, because the current level of testing is unknown and is likely to vary across the country. Organisations should therefore estimate this locally and assess any potential cost impact of increases in the numbers of CA125 tests and ultrasounds. 4 The unit cost used is based on the health economics section of the ovarian cancer full guideline. However, expert opinion suggests that local costs may be lower. 5 There is additional 30 reporting fee for this scan. 6 There is additional 28 reporting fee for this scan. Costing statement: Ovarian cancer (April 2011) 4

5 4.1.2 Establishing the diagnosis in secondary care (recommendations , and ) For women under 40 with suspected ovarian cancer, further tests to measure levels of alpha fetoprotein (AFP) and beta human chorionic gonadotrophin (beta-hcg), as well as serum CA125, may be required to identify women who may not have epithelial ovarian cancer. If serum CA125, ultrasound and clinical status suggest ovarian cancer, the guideline recommends that a CT scan of the pelvis and abdomen (and thorax if clinically indicated) is performed. Although this may not be an additional procedure compared with current practice, it may happen earlier in the process than at present. 4.2 Management of suspected early (stage I) ovarian cancer Retroperitoneal lymph node assessment and systematic retroperitoneal lymphadenectomy (SRL) (recommendations ) The guideline recommends that retroperitoneal lymph node assessment 7 is performed as part of optimal surgical staging 8 in women with suspected ovarian cancer whose disease appears to be confined to the ovaries (that is, who appear to have stage I disease). However, SRL (block dissection of lymph nodes from the pelvic side walls to the level of the renal veins) is not recommended as part of standard surgical treatment in women who appear to have stage I ovarian cancer. SRL for women who appear to have stage I ovarian cancer is not standard practice in England. Because the guideline recommends that SRL is not 7 Lymph node assessment involves sampling of retroperitoneal lymphatic tissue from the para-aortic area and pelvic side walls if there is a palpable abnormality, or random sampling if there is no palpable abnormality. 8 Optimal surgical staging constitutes midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy; biopsies of any peritoneal deposits; random biopsies of the pelvic and abdominal peritoneum and retroperitoneal lymph node assessment Costing statement: Ovarian cancer (April 2011) 5

6 included as part of standard surgical treatment for women who appear to have stage I ovarian cancer, there might be savings in surgical costs if organisations that currently do carry out SRL for such women implement this recommendation. However, we do not anticipate any significant potential savings at a national level, because the number of women involved is relatively small. Organisations should investigate and assess any potential savings locally. There is an average saving of 1200 per procedure if retroperitoneal lymph node assessment is performed instead of SRL (see table 3 for unit costs) Not offering adjuvant systematic chemotherapy to women who have had optimal surgical staging and have low-risk stage I disease (recommendation ) Feedback from the Guideline Development Group (GDG) suggests that this recommendation is not a change in practice. It is relevant to a relatively small number of women with ovarian cancer. However, organisations are encouraged to review clinical practice and estimate any potential savings locally Offering women with high-risk stage I disease (grade 3 or stage Ic) adjuvant chemotherapy consisting of six cycles of carboplatin (recommendation ) Feedback from the GDG suggests that adjuvant chemotherapy would be available to only a relatively small number of women with stage I ovarian cancer, based on this recommendation. Therefore the recommendation is not expected to have a significant cost impact at a national level. However, organisations should assess any potential cost implications locally. Costing statement: Ovarian cancer (April 2011) 6

7 The cost of six cycles of carboplatin is , based on a dose of 400 mg/m 2 body surface area and assuming an average body surface area of 1.7 m Management of advanced (stage II IV) ovarian cancer Not offering intraperitoneal chemotherapy to women with ovarian cancer, except as part of a clinical trial (recommendation ) Intraperitoneal chemotherapy is not routine practice across England, and feedback from the GDG suggests the recommendation relates to only a relatively small number of women. In areas where intraperitoneal chemotherapy is currently offered to women with ovarian cancer outside of a clinical trial, cash savings are likely to be achieved. Organisations are therefore encouraged to review their services and estimate any potential savings locally. 4.4 Support needs of women with newly diagnosed ovarian cancer Offering all women with newly diagnosed ovarian cancer information about psychosocial and psychosexual issues (recommendations and ) It is likely that women with ovarian cancer already receive information about psychosocial and psychosexual issues, based on the Department of Health s guidance on Improving outcomes in gynaecological cancers 10. That guidance made recommendations on the need for effective communication, delivery of 9 The prices quoted for drugs are the prices given in the 'British national formulary' (BNF) edition 61. This is net of VAT. If drugs are purchased by a hospital pharmacy, they will be subject to VAT. Some hospitals negotiate discounts from suppliers depending on level of spend; this discount varies between organisations. The unit cost of carboplatin includes the cost of intravenous administration. 10 Improving outcomes in gynaecological cancers. Cancer service guidance (1999). Department of Health, National Cancer Guidance Steering Group. Available from: dh_ pdf Costing statement: Ovarian cancer (April 2011) 7

8 relevant and timely information, and psychological and psychosexual support and counselling. Commissioners should review local practice in this area and estimate costs locally in order to ensure that this guidance has been implemented. 5 Savings and benefits Implementing the guideline will remove both uncertainty and wide variation in clinical practice with regard to the detection, diagnosis and initial management of ovarian cancer. Implementing this guideline is anticipated to have the following benefits that are not possible to quantify: Women who display symptoms of ovarian cancer will receive a timely diagnosis.this potentially avoids the need for more expensive treatment at a later date. There will be improved outcomes for women with ovarian cancer as a result of earlier diagnosis and treatment. Women are less likely to present with more advanced ovarian cancer. This potentially reduces secondary care costs in the future. Woman will get access to the correct type of care for ovarian cancer, and incorrect referrals to other cancer specialties should be reduced. This potentially avoids wasting NHS resources in other cancer specialties. 6 Conclusion Although implementation of the NICE guideline on the recognition and initial management of ovarian cancer may require investment in tests in primary care, this is likely to be offset by savings and benefits associated with guideline implementation. Therefore implementation of the guideline is unlikely to have a significant impact on NHS resources at a national level. However, there is recognition that clinical practice varies across the country, and therefore organisations should monitor their expenditure trends in this area at a local level. Costing statement: Ovarian cancer (April 2011) 8

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