Cost-Effectiveness of Hepatocellular Carcinoma Surveillance: An Assessment of Benefits and Harms - PubMed (original) (raw)
Cost-Effectiveness of Hepatocellular Carcinoma Surveillance: An Assessment of Benefits and Harms
Neehar D Parikh et al. Am J Gastroenterol. 2020 Oct.
Abstract
Introduction: The value of hepatocellular carcinoma (HCC) surveillance is defined by the balance of benefits, i.e., early tumor detection, and potential harms, related to false positive and indeterminate results. Although physical harms can be observed in 15%-20% of patients with cirrhosis undergoing HCC surveillance, previous cost-effectiveness analyses have not incorporated costs of harms. We aimed to evaluate the cost-effectiveness of HCC surveillance including both benefits and harms.
Design: We constructed a Markov model to compare surveillance strategies of ultrasound (US) alone, US and alpha fetoprotein (AFP), and no surveillance in 1 million simulated patients with compensated cirrhosis. Harms included imaging and biopsy in patients undergoing surveillance for HCC. Model inputs were based on literature review, and costs were derived from the Medicare fee schedule, with all costs inflated to 2018 dollars. The primary outcome was the incremental cost-effectiveness ratio per incremental quality-adjusted life-year.
Results: In the base case analysis, US with AFP was the dominant strategy over both US alone and no surveillance. In a probabilistic sensitivity analysis, US with AFP was the most cost-effective strategy in 80.1% of simulations at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year. In our threshold analyses, an HCC incidence >0.4% per year and surveillance adherence >19.5% biannually were necessary for US with AFP to be cost-effective compared with no surveillance.
Discussion: Accounting for both surveillance-related benefits and harms, US and AFP is more cost-effective for HCC surveillance than US alone or no surveillance in patients with compensated cirrhosis.
Conflict of interest statement
Conflicts of Interest: Dr. Singal has been on advisory boards and served as a consultant for Wako Diagostics, Roche, Exact Sciences, Glycotest, Bayer, Eisai, BMS, Exelixis, and Merck. Dr Tapper served on advisory boards and was a consultant for Bausch Health, Rebiotix, Mallinckrodt, Kaleido, Novartis, and Allergan. Dr. Parikh has served on advisory boards for Bayer, Eisai, Exelixis, Wako; Research Grants: TARGET Pharmasolutions, Bayer, Exact Sciences, Glycotest and a consultant for Exelixis, Bristol-Myers Squibb, Eli Lilly, Freenome.
Figures
Figure 1.
Tornado plot showing one-way sensitivity analyses for ultrasound versus no surveillance
Figure 2.
Cost-effectiveness acceptability curves for no surveillance, ultrasound surveillance, and surveillance with ultrasound and alpha fetoprotein.
Figure 3a.
Threshold analysis of the cost per quality adjusted life year with varying hepatocellular carcinoma incidence
Figure 3b.
Threshold analysis of the cost per quality adjusted life year with varying adherence to hepatocellular carcinoma surveillance strategies
References
- Bray F, Ferlay J, Soerjomataram I, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians 2018;68:394–424. - PubMed
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