Hepatocellular carcinoma surveillance based on the Australian Consensus Guidelines: a health economic modelling study

Abstract

Background: Hepatocellular carcinoma (HCC) is the fastest increasing cause of cancer death in Australia. A recent Australian consensus guidelines recommended HCC surveillance for cirrhotic patients and non-cirrhotic chronic hepatitis B (CHB) patients at gender and age specific cut-offs. A cost-effectiveness model was then developed to assess surveillance strategies in Australia.

Methods: A microsimulation model was used to evaluate three strategies: biannual ultrasound, biannual ultrasound with alpha-fetoprotein (AFP) and no formal surveillance for patients having one of the conditions: non-cirrhotic CHB, compensated cirrhosis or decompensated cirrhosis. One-way and probabilistic sensitivity analyses as well as scenario and threshold analyses were conducted to account for uncertainties: including exclusive surveillance of CHB, compensated cirrhosis or decompensated cirrhosis populations; impact of obesity on ultrasound sensitivity; real-world adherence rate; and different cohort's ranges of ages.

Results: Sixty HCC surveillance scenarios were considered for the baseline population. The ultrasound + AFP strategy was the most cost-effective with incremental cost-effectiveness ratios (ICER) compared to no surveillance falling below the willingness-to-pay threshold of A$50,000 per quality-adjusted life year (QALY) at all age ranges. Ultrasound alone was also cost-effective, but the strategy was dominated by ultrasound + AFP. Surveillance was cost-effective in the compensated and decompensated cirrhosis populations alone (ICERs < $30,000), but not cost-effective in the CHB population (ICERs > $100,000). Obesity could decrease the diagnostic performance of ultrasound, which in turn, reduce the cost-effectiveness of ultrasound ± AFP, but the strategies remained cost-effective.

Conclusions: HCC surveillance based on Australian recommendations using biannual ultrasound ± AFP was cost-effective.

Keywords: Alpha-fetoprotein; Cost-effectiveness; Hepatocellular carcinoma; Surveillance; Ultrasound.

Fig. 1

Structure of the state-transition individual-level model

Fig. 2

Tornado diagram of Ultrasound surveillance on baseline population at age range 40–80

Fig. 3

Tornado diagram of Ultrasound + AFP surveillance on baseline population at age range 40–80

Fig. 4

Cost-effectiveness acceptability curves for surveillance at real adherence rate and status quo using baseline population aged 40 to 80 years