title: Which is more cost-effective under the MELD system: primary liver transplantation, or salvage transplantation after hepatic resection or after loco-regional therapy for hepatocellular carcinoma within Milan criteria?
abstract: OBJECTIVE
  The optimal strategy for treating hepatocellular carcinoma (HCC), a disease with increasing incidence, in patients with Child-Pugh class A cirrhosis has long been debated. This study evaluated the cost-effectiveness of hepatic resection (HR) or locoregional therapy (LRT) followed by salvage orthotopic liver transplantation (SOLT) vs. that of primary orthotopic liver transplantation (POLT) for HCC within the Milan Criteria.
  
  
  METHODS
  A Markov-based decision analytic model simulated outcomes, expressed in costs and quality-adjusted life years (QALYs), for the three treatment strategies. Baseline parameters were determined from a literature review. Sensitivity analyses tested model strength and parameter variability.
  
  
  RESULTS
  Both HR and LRT followed by SOLT were associated with earlier recurrence, decreased survival, increased costs and decreased quality of life (QoL), whereas POLT resulted in decreased recurrence, increased survival, decreased costs and increased QoL. Specifically, HR/SOLT yielded 3.1 QALYs (at US$96 000/QALY) and LRT/SOLT yielded 3.9 QALYs (at US$74 000/QALY), whereas POLT yielded 5.5 QALYs (at US$52 000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities.
  
  
  CONCLUSIONS
  Under the Model for End-stage Liver Disease (MELD) system, in patients with HCC within the Milan Criteria, POLT increases survival and QoL at decreased costs compared with HR or LRT followed by SOLT. Therefore, POLT is the most cost-effective strategy for the treatment of HCC.
authors: Department of Surgery, Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA.
authors: Matthew P
authors: MP
authors: Landman
authors: Irene D
authors: ID
authors: Feurer
authors: C Wright
authors: CW
authors: Pinson
authors: Derek E
authors: DE
authors: Moore
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000191:economics* / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D003198:Computer Simulation; D003661:Decision Support Techniques; D003663:Decision Trees; D017048:Health Care Costs; D006498:Hepatectomy / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D006801:Humans; D008113:Liver Neoplasms / Q000175:diagnosis / Q000191:economics* / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D008390:Markov Chains; D018803:Models, Economic; D009364:Neoplasm Recurrence, Local; D018579:Patient Selection; D019057:Quality-Adjusted Life Years; D016879:Salvage Therapy / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome