Cost-Effectiveness of the Surveillance Program of HCC
Cost-Effectiveness of the Surveillance Program of HCC
Background and Aim: The clinical features of hepatocellular carcinoma (HCC) and the medical environment are diverse in different geographic areas. The aim of this study is to evaluate the cost-effectiveness of the surveillance of HCC in different medical circumstances.
Methods: The Markov model focused on variables that differ from country to country and may change in the future, especially in regards to the proportion of small HCC detected incidentally. The target population was 45-year-old patients with Child-Pugh class A cirrhosis, and the intervention was surveillance with ultrasonography every 6 months.
Results: The additional cost of the surveillance was $US15 100, the gain in quality-adjusted life years (QALYs) was 0.50 years, and the incremental cost-effectiveness ratio (ICER) was $US29 900/QALY in a base-case analysis (annual incidence of HCC = 4%). If 40% of small HCC were detected incidentally without surveillance, the gain in QALY decreased to 0.15 and the ICER increased to $US47 900/QALY. The increase in the annual incidence of HCC to 8% resulted in the increase of QALYs to 0.81, and the decrease of the ICER to $US25 400/QALY. The adoption of liver transplantation increased the gain in QALYs and the ICER to 0.84 and $US59 900/QALY, respectively.
Conclusions: The gain in QALYs and the ICER due to the surveillance of HCC varies between different patient subgroups and it critically depends on the rate of small HCC detected incidentally without surveillance, as well as the annual incidence of HCC and the adoption of liver transplantation.
Hepatocellular carcinoma (HCC) is one of the most prevalent malignancies worldwide and more than 500 000 new cases are diagnosed yearly. Liver cirrhosis (LC) is a strong predisposing factor of HCC and 80% of patients with HCC suffered from LC. Hepatitis B or C virus infection are the two major causes of LC and the annual incidence of HCC in patients with LC is between 1% and 8%. Due to increasing knowledge of the risk factors of HCC, a screening program for the detection of early HCC has been recommended to decrease the incidence of tumor related death. α-fetoprotein (AFP), ultrasonography (US), magnetic resonance imaging, and spiral-computed tomography (CT) have been used for the surveillance of HCC and recent American Association for the Study of Liver Diseases (AASLD) practice guidelines recommended the screening of cirrhotic patients only with US.
The stage of HCC at the time of diagnosis differs from country to country. Surveillance programs have been known to increase the percentage of small HCC at diagnosis that are amenable to potentially curative treatments, such as local ablation therapies, resection, or liver transplantation, and the popularization of surveillance programs seems to be one of the major factors causing this difference. In addition, there is another important factor causing the difference, which is the difference in the size of HCC in the no-surveillance group. In cohort studies of surveillance, the size of HCC in the surveillance group was usually small and relatively uniform. In contrast, the sizes of HCC detected without surveillance were large and varied among studies (4-8 cm). HCC in the no-surveillance group was detected in two different manners: incidentally (asymptomatic, discovered outside of the regular surveillance programs or by diagnostic procedures for other diseases) and by the appearance of symptoms. HCC detected incidentally without symptoms was found earlier and was smaller in size than symptomatic HCC, and the ratio of these two groups seems to be one of the major determinants of the size of HCC in the no-surveillance group. Most of the studies, including simulation studies using the Markov model that analyzed the cost-effectiveness of surveillance for HCC, compared HCC found by surveillance and symptomatic HCC. These studies did not focus on the small HCC detected incidentally that is frequently observed, especially in medically developed countries.
Treatment strategies are different in different geographic areas and in particular, the feasibility of liver transplantation differs markedly. For example, the legal and societal constraints on cadaveric liver transplantations existing in Asia and the shortage of donors relative to the numbers of recipients limit the possibility of transplantation. As a result, the applicability of liver transplantation in Asia is marginal, whereas this procedure is frequently performed in the United States and Europe. The incremental cost effectiveness of the surveillance of HCC was reported to be increased due to the introduction of transplantation for the therapy of small HCC and decompensated cirrhosis; however, the effect of liver transplantation in conjunction with other factors that vary in different geographic areas, such as the rate of small HCC detected incidentally in the no-surveillance group, has not yet been proven.
To determine the cost-effectiveness of the surveillance program in different districts with different medical environments, and to find out the conditions of cost-effective surveillance of HCC, we constructed a Markov model and performed an analysis.
Background and Aim: The clinical features of hepatocellular carcinoma (HCC) and the medical environment are diverse in different geographic areas. The aim of this study is to evaluate the cost-effectiveness of the surveillance of HCC in different medical circumstances.
Methods: The Markov model focused on variables that differ from country to country and may change in the future, especially in regards to the proportion of small HCC detected incidentally. The target population was 45-year-old patients with Child-Pugh class A cirrhosis, and the intervention was surveillance with ultrasonography every 6 months.
Results: The additional cost of the surveillance was $US15 100, the gain in quality-adjusted life years (QALYs) was 0.50 years, and the incremental cost-effectiveness ratio (ICER) was $US29 900/QALY in a base-case analysis (annual incidence of HCC = 4%). If 40% of small HCC were detected incidentally without surveillance, the gain in QALY decreased to 0.15 and the ICER increased to $US47 900/QALY. The increase in the annual incidence of HCC to 8% resulted in the increase of QALYs to 0.81, and the decrease of the ICER to $US25 400/QALY. The adoption of liver transplantation increased the gain in QALYs and the ICER to 0.84 and $US59 900/QALY, respectively.
Conclusions: The gain in QALYs and the ICER due to the surveillance of HCC varies between different patient subgroups and it critically depends on the rate of small HCC detected incidentally without surveillance, as well as the annual incidence of HCC and the adoption of liver transplantation.
Hepatocellular carcinoma (HCC) is one of the most prevalent malignancies worldwide and more than 500 000 new cases are diagnosed yearly. Liver cirrhosis (LC) is a strong predisposing factor of HCC and 80% of patients with HCC suffered from LC. Hepatitis B or C virus infection are the two major causes of LC and the annual incidence of HCC in patients with LC is between 1% and 8%. Due to increasing knowledge of the risk factors of HCC, a screening program for the detection of early HCC has been recommended to decrease the incidence of tumor related death. α-fetoprotein (AFP), ultrasonography (US), magnetic resonance imaging, and spiral-computed tomography (CT) have been used for the surveillance of HCC and recent American Association for the Study of Liver Diseases (AASLD) practice guidelines recommended the screening of cirrhotic patients only with US.
The stage of HCC at the time of diagnosis differs from country to country. Surveillance programs have been known to increase the percentage of small HCC at diagnosis that are amenable to potentially curative treatments, such as local ablation therapies, resection, or liver transplantation, and the popularization of surveillance programs seems to be one of the major factors causing this difference. In addition, there is another important factor causing the difference, which is the difference in the size of HCC in the no-surveillance group. In cohort studies of surveillance, the size of HCC in the surveillance group was usually small and relatively uniform. In contrast, the sizes of HCC detected without surveillance were large and varied among studies (4-8 cm). HCC in the no-surveillance group was detected in two different manners: incidentally (asymptomatic, discovered outside of the regular surveillance programs or by diagnostic procedures for other diseases) and by the appearance of symptoms. HCC detected incidentally without symptoms was found earlier and was smaller in size than symptomatic HCC, and the ratio of these two groups seems to be one of the major determinants of the size of HCC in the no-surveillance group. Most of the studies, including simulation studies using the Markov model that analyzed the cost-effectiveness of surveillance for HCC, compared HCC found by surveillance and symptomatic HCC. These studies did not focus on the small HCC detected incidentally that is frequently observed, especially in medically developed countries.
Treatment strategies are different in different geographic areas and in particular, the feasibility of liver transplantation differs markedly. For example, the legal and societal constraints on cadaveric liver transplantations existing in Asia and the shortage of donors relative to the numbers of recipients limit the possibility of transplantation. As a result, the applicability of liver transplantation in Asia is marginal, whereas this procedure is frequently performed in the United States and Europe. The incremental cost effectiveness of the surveillance of HCC was reported to be increased due to the introduction of transplantation for the therapy of small HCC and decompensated cirrhosis; however, the effect of liver transplantation in conjunction with other factors that vary in different geographic areas, such as the rate of small HCC detected incidentally in the no-surveillance group, has not yet been proven.
To determine the cost-effectiveness of the surveillance program in different districts with different medical environments, and to find out the conditions of cost-effective surveillance of HCC, we constructed a Markov model and performed an analysis.
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