title: Comparative and cost effectiveness of treatment modalities for hepatocellular carcinoma in SEER-Medicare.
abstract: BACKGROUND
  The incidence of hepatocellular carcinoma (HCC) is increasing in the USA and worldwide. Several treatments are available for patients diagnosed at any disease stage. It remains unclear how medical expenditures vary across patients who remain untreated or undergo different modes of therapy. We evaluate the comparative and cost effectiveness of treatment modalities for HCC from a Medicare perspective.
  
  
  METHODS
  The Surveillance, Epidemiology, and End Results (SEER) registries and linked Medicare database with claims from Parts A/B were used to identify Medicare enrollees with initial diagnosis of HCC between 2000 and 2007 and followed through 2009. Patients were assigned to treatment modalities based on HCC staging systems: transplant, resection, liver directed, radiation, chemotherapy or no treatment. Survival benefits and cumulative Medicare expenditures were estimated in multivariate models, stratified by initial disease stage, to control for confounding. Cost-effectiveness ratios compared costs and benefits of the modalities across initial stages.
  
  
  RESULTS
  Cancer stages I, II, III, IV and unstaged represented 24, 9, 14, 17 and 37 % of 11,047 patients, respectively. Fewer than 40 % received any treatment. Relative to no treatment, transplant was most effective in reducing mortality, followed by resection, liver directed, and radiation or chemotherapy. Resection tended to be most cost effective in early staged and unstaged patients; transplant was least cost effective. In stage IV patients, liver directed therapy was more cost effective than chemotherapy or radiation.
  
  
  CONCLUSIONS
  Survival benefit was attributable to all treatment modalities. More effective treatments incurred greater Medicare expenditures, but resection patients incurred the least expenditures per year of life gained.
authors.affiliation: Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, 12th floor, Baltimore, MD, 21201, USA, fshaya@rx.umaryland.edu.
authors.forename: Fadia T
authors.initials: FT
authors.lastname: Shaya
authors.forename: Ian M
authors.initials: IM
authors.lastname: Breunig
authors.forename: Brian
authors.initials: B
authors.lastname: Seal
authors.forename: C Daniel
authors.initials: CD
authors.lastname: Mullins
authors.forename: Viktor V
authors.initials: VV
authors.lastname: Chirikov
authors.forename: Nader
authors.initials: N
authors.lastname: Hanna
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000191:economics / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D003362:Cost-Benefit Analysis; D004358:Drug Therapy / Q000191:economics*; D005260:Female; D017048:Health Care Costs; D006498:Hepatectomy / Q000191:economics*; D006801:Humans; D008113:Liver Neoplasms / Q000191:economics / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D016031:Liver Transplantation / Q000191:economics*; D008297:Male; D006278:Medicare; D008875:Middle Aged; D009367:Neoplasm Staging; D011878:Radiotherapy / Q000191:economics*; D018426:SEER Program; D016019:Survival Analysis; D014481:United States