title: Liver Resection for Advanced Intrahepatic Cholangiocarcinoma: A Cost-Utility Analysis.
abstract: BACKGROUND
  Data on cost-effectiveness and efficacy of hepatic resection (HR) for advanced intrahepatic cholangiocarcinoma (ICC) are lacking. We sought to estimate the cost-effectiveness of upfront HR resulting in an R1 resection (strategy A) relative to initial systemic chemotherapy (sCT) followed by possible curative HR (strategy B) for patients with advanced ICC.
  
  
  METHODS
  A Markov model was developed using data from a systematic literature review. Three base cases were considered: (1) ICC >6 cm (2) ICC with vascular invasion (3) multi-focal ICC. A Monte Carlo simulation assessed outcomes including quality-adjusted life months (QALMs) and incremental cost-effectiveness ratio (ICER).
  
  
  RESULTS
  The net health benefit (NHB) of strategy A versus strategy B was 1.4 QALMs for ICC >6 cm and 1.3 QALMs for ICC and vascular invasion; in contrast, there was a negative NHB for HR versus sCT for multi-focal ICC (-0.3 QALMs). In single nodule ICC >6 cm, the ICER of HR versus sCT was $22,482/quality-adjusted life years (QALY) and the ICER of HR versus sCT was $20,953/QALY for ICC with vascular invasion. In multi-focal ICC, the ICER of HR compared with sCT was $83,604/QALY. Patients with a higher American Society of Anesthesiologists score (coefficient 0.94), male sex (coefficient 0.43), low quality of life after sCT (coefficient -2.57) and T3 tumors (coefficient 0.53) had a better NHB for HR relative to sCT followed by potential surgery.
  
  
  CONCLUSIONS
  For patients with large ICC or ICC and vascular invasion, HR was more cost-effective than sCT. In contrast, HR was not associated with a positive NHB relative to sCT for patients with multi-focal ICC, and therefore these patients should be treated with sCT rather than HR.
authors.affiliation: Unità di Chirurgia Epatobiliare e Trapianto Epatico, Azienda Ospedaliera-Università di Padova, Padua, Italy.
authors.forename: Umberto
authors.initials: U
authors.lastname: Cillo
authors.forename: Gaya
authors.initials: G
authors.lastname: Spolverato
authors.forename: Alessandro
authors.initials: A
authors.lastname: Vitale
authors.forename: Aslam
authors.initials: A
authors.lastname: Ejaz
authors.forename: Sara
authors.initials: S
authors.lastname: Lonardi
authors.forename: David
authors.initials: D
authors.lastname: Cosgrove
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001650:Bile Duct Neoplasms / Q000188:drug therapy / Q000473:pathology* / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic; D001808:Blood Vessels / Q000473:pathology; D017024:Chemotherapy, Adjuvant; D018281:Cholangiocarcinoma / Q000188:drug therapy / Q000473:pathology* / Q000601:surgery*; D003362:Cost-Benefit Analysis; D005260:Female; D006498:Hepatectomy / Q000191:economics*; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009361:Neoplasm Invasiveness; D009378:Neoplasms, Multiple Primary / Q000188:drug therapy / Q000473:pathology* / Q000601:surgery*; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D047368:Tumor Burden; D055815:Young Adult