Cost effectiveness of alternative surveillance strategies for hepatocellular carcinoma in patients with cirrhosis

Abstract

Background & aims: The increasing incidence of hepatocellular carcinoma (HCC) in the United States has significant health and economic consequences. Ultrasound (US) surveillance is recommended for patients with cirrhosis because of their high risk of HCC and improving treatment outcomes for small tumors. We assessed the costs, clinical benefits, and cost effectiveness of US surveillance and alternative strategies for HCC in cirrhosis using a computer-based state transition model with parameters derived from available literature.

Methods: Our model compared a policy of no surveillance with 6 surveillance strategies in cirrhotic patients ages 50 years and older in the United States: (1) annual US, (2) semiannual US, (3) semiannual US with alpha-fetoprotein, (4) annual computed tomography (CT), (5) semiannual CT, and (6) annual magnetic resonance imaging. The number of screening tests needed to detect one small HCC, cost per treated HCC, lifetime costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios were calculated.

Results: Semiannual US surveillance for HCC in cirrhosis increased quality-adjusted life expectancy by 8.6 months on average, but extended it nearly 3.5 years in patients with small treated tumors. Semiannual US surveillance had an incremental cost-effectiveness ratio of $30,700 per quality-adjusted life year (QALY) gained, and was more cost effective than the alternative surveillance strategies using a threshold of $50,000 per QALY gained. The incremental cost-effectiveness ratios for the combined alpha-fetoprotein/US and annual CT strategies exceeded $50,000/QALY unless the sensitivity and specificity of US decreased to less than 65% and 60%, respectively.

Conclusions: Semiannual US surveillance for HCC in cirrhotic patients improves clinical outcomes at a reasonable cost.

Figure 1

Simplified schematic of Markov health states. In each cycle, individuals may remain in the same health state, transition to the following state, or die from liver disease or unrelated causes. For example, transition 1 reflects cancer incidence; transition 2 is determined by the sensitivity of the surveillance modality; and transition 3 is the proportion of treatment-eligible tumors. Best available data were used to determine transitions. The grey boxes represent the possible benefit of surveillance: detection and treatment of small HCC.

Figure 2

Sensitivity analysis. The effect of varying selected model variables on the ICER of semiannual US surveillance. The values in parentheses are the baseline values for each variable and the plausible range tested in sensitivity analyses. The dashed line indicates the ICER in the base case. The bars show the variability of the ICER caused by changes in the indicated variable, all other variables held constant.