Hepatocellular carcinoma screening in patients waiting for liver transplantation: a decision analytic model.
De novo hepatocellular carcinoma (HCC) may have a large impact on patients waiting for liver transplantation. The presence of HCC can lead to a status upgrade or removal from the waitlist. Our aim is to compare costs and outcomes of different liver cancer surveillance strategies. A Markov-based decision analytic model is created to simulate costs and health outcomes for a hypothetical cohort awaiting liver transplantation undergoing HCC screening. Three strategies of HCC screening are compared with the referent strategy of using alphafetaprotein (AFP) level alone: (1) ultrasound (U/S), (2) AFP plus U/S, and (3) computed tomography (CT). Screening is performed for all strategies at 6-month intervals. Selected tumors are treated locally. Costs and clinical outcomes are discounted. Using baseline assumptions, incremental cost-effectiveness ratios (ICERs) for U/S, U/S plus AFP, and CT are $60,300/life-year saved (LY), $74,000/LY, and $101,100/LY, respectively. The most cost-effective strategy was dependent on the relative costs of each screening modality. U/S screening becomes the dominant strategy when the cost of an AFP test is decreased. Our results show that screening with CT is associated the greatest gain in life expectancy and greatest costs. U/S screening strategy is the preferred screening strategy based on the lowest ICER. Ultimately, costs of the screening modalities determine the most cost-effective strategy.
Saab
Sammy
S
Department of Medicine, Dumont-UCLA Liver Transplant Center, University of California Los Angeles, USA. Ssaab@mednet.ucla.edu
Ly
David
D
Nieto
Jose
J
Kanwal
Fasiha
F
Lu
David
D
Raman
Steven
S
Amado
Rafael
R
Nuesse
Barbara
B
Durazo
Francisco
F
Han
Steven
S
Farmer
Douglas G
DG
Ghobrial
Rafik M
RM
Yersiz
Hasan
H
Chen
Pauline
P
Schwegel
Kathy
K
Goldstein
Leonard I
LI
Tong
Myron
M
Busuttil
Ronald W
RW
D006528:Carcinoma, Hepatocellular / Q000175:diagnosis* / Q000601:surgery; D003362:Cost-Benefit Analysis; D003658:Decision Making, Computer-Assisted; D003663:Decision Trees; D017048:Health Care Costs; D006801:Humans; D008107:Liver Diseases / Q000601:surgery; D008113:Liver Neoplasms / Q000175:diagnosis* / Q000601:surgery; D016031:Liver Transplantation / Q000191:economics / Q000379:methods; D008403:Mass Screening / Q000191:economics; D010043:Outcome and Process Assessment, Health Care; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography; D014850:Waiting Lists; D000509:alpha-Fetoproteins / Q000032:analysis
D000509:alpha-Fetoproteins