title: Cost-effectiveness analysis of liver resection versus transplantation for early hepatocellular carcinoma within the Milan criteria.
abstract: Both liver resection (LR) and cadaveric liver transplantation (CLT) are potentially curative treatments for patients with hepatocellular carcinoma (HCC) within the Milan criteria and with adequate liver function. Adopting either as a first-line therapy carries major cost and resource implications. The objective of this study was to estimate the relative cost-effectiveness of LR against CLT for patients with HCC within the Milan criteria using a decision analytic model. A Markov cohort model was developed to simulate a cohort of patients aged 55 years with HCC within the Milan criteria and Child-Pugh A/B cirrhosis, undergoing LR or CLT, and followed up over their remaining life expectancy. Analysis was performed in different geographical cost settings: the USA, Switzerland and Singapore. Transition probabilities were obtained from systematic literature reviews, supplemented by databases from Singapore and the Organ Procurement and Transplantation Network (USA). Utility and cost data were obtained from open sources. LR produced 3.9 quality-adjusted life years (QALYs) while CLT had an additional 1.4 QALYs. The incremental cost-effectiveness ratio (ICER) of CLT versus LR ranged from $111,821/QALY in Singapore to $156,300/QALY in Switzerland, and was above thresholds for cost-effectiveness in all three countries. Sensitivity analysis revealed that CLT-related 5-year cumulative survival, one-time cost of CLT, and post-LR 5-year cumulative recurrence rates were the most sensitive parameters in all cost scenarios. ICERs were reduced below threshold when CLT-related 5-year cumulative survival exceeded 84.9% and 87.6% in Singapore and the USA, respectively. For Switzerland, the ICER remained above the cost-effectiveness threshold regardless of the variations.
  
  
  CONCLUSIONS
  In patients with HCC within the Milan criteria and Child-Pugh A/B cirrhosis, LR is more cost-effective than CLT across three different costing scenarios: the USA, Switzerland, Singapore.
authors.affiliation: Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore; Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore.
authors.forename: Kheng Choon
authors.initials: KC
authors.lastname: Lim
authors.forename: Vivian W
authors.initials: VW
authors.lastname: Wang
authors.forename: Fahad J
authors.initials: FJ
authors.lastname: Siddiqui
authors.forename: Luming
authors.initials: L
authors.lastname: Shi
authors.forename: Edwin S Y
authors.initials: ES
authors.lastname: Chan
authors.forename: Hong Choon
authors.initials: HC
authors.lastname: Oh
authors.forename: Say Beng
authors.initials: SB
authors.lastname: Tan
authors.forename: Pierce K H
authors.initials: PK
authors.lastname: Chow
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000191:economics / Q000601:surgery*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D006801:Humans; D008113:Liver Neoplasms / Q000191:economics / Q000601:surgery*; D016031:Liver Transplantation / Q000191:economics*; D008390:Markov Chains; D008875:Middle Aged; D018803:Models, Economic; D012846:Singapore; D013557:Switzerland; D014481:United States