Cost-effectiveness analysis of HRD testing for patients with advanced ovarian cancer in Italy: an update

Introduction Ovarian cancer (OC) is the eighth most common cancer among women, with homologous recombination deficiency (HRD) present in about 50% of cases. In this subgroup, poly (ADP-ribose) polymerase (PARP) inhibitors show greater therapeutic benefit. This study aimed to update a cost-effectiveness analysis comparing upfront HRD testing with BRCA-only testing (BReast CAncer gene), which identifies mutations in roughly 25% of patients, to inform and optimize treatment strategies in Italy. Methods A previously developed cost-effectiveness model was updated to incorporate new clinical evidence and cost data for PARP inhibitors (niraparib, rucaparib). The model projected costs and outcomes - life-years (LYs) and quality-adjusted life-years (QALYs) - over a lifetime horizon, comparing immediate HRD testing with BRCA testing alone or with sequential HRD testing after a negative BRCA result. Analyses were conducted from the Italian National Healthcare Service (NHS) perspective. Deterministic and probabilistic sensitivity analyses, together with scenario and threshold analyses, assessed the robustness of model results. Results Upfront HRD testing remained cost-effective versus BRCA-only testing, with an incremental cost-utility ratio of 22,476€/QALY, and was cost-saving compared with sequential testing. Probabilistic sensitivity analysis showed that HRD testing was cost-effective in 99.3% of simulations considering a 50,000€/QALY willingness-to-pay threshold. Findings were robust across most scenarios, however cost-effectiveness was reversed with a 10-year time horizon, an HRD-positive/BRCA-negative prevalence in the range 3.95%-4.99%, or substantial acquisition cost increases for olaparib or rucaparib. Discussion Although identifying genetic alterations in advanced OC incurs significant costs, upfront HRD testing is a cost-effective strategy compared with BRCA-only testing when considering all currently available treatment options. It enables more efficient allocation of healthcare resources while improving life expectancy and quality of life for women with advanced ovarian cancer.