title: Cost-effectiveness analysis of hepatocellular carcinoma screening by combinations of ultrasound and alpha-fetoprotein among Alaska Native people, 1983-2012.
abstract: The American Association for the Study of Liver Diseases (AASLD) recommends semi-annual hepatocellular carcinoma (HCC) screening using ultrasound (US) in persons with chronic hepatitis B (CHB) virus infection at high risk for HCC such as Asian males aged ≥40 years and Asian females aged ≥50 years.
  
  
  
  To analyse the cost-effectiveness of 2 HCC screening methods in the Alaska Native (AN) health system: US-alone, or screening by alpha-fetoprotein (AFP) initially and switching to US for subsequent screenings if AFP >10 ng/mL (AFP→US).
  
  
  
  A spreadsheet-based model was developed for accounting the costs of 2 hypothetical HCC screening methods. We used epidemiologic data from a cohort of 839 AN persons with CHB who were offered HCC screening by AFP/US semi-annually during 1983-2012. We assumed that compared with AFP→US, US-alone identifies 33% more tumours at an early stage (defined as a single tumour ≤5 cm or ≤3 tumours ≤3 cm in diameter). Years of life gained (YLG) attributed to screening was estimated by comparing additional years of survival among persons with early- compared with late-stage tumours. Screening costs were calculated using Medicare reimbursement rates in 2012. Future screening costs and YLG were projected over a 30-year time horizon using a 3% discount rate.
  
  
  
  The total cost of screening for the cohort by AFP→US would have been approximately $357,000 ($36,000/early-stage tumour detected) compared to $814,000 ($59,000/early-stage tumour detected) by US-alone. The AFP→US method would have yielded an additional 27.8 YLG ($13,000/YLG) compared with 38.9 YLG ($21,000/YLG) for US-alone. Screening by US-alone would incur an additional $114,000 per extra early-tumour detected compared with AFP→US and $41,000 per extra YLG.
  
  
  
  Although US-alone HCC screening might have yielded more YLG than AFP→US, the reduced costs of the AFP→US method could expand access to HCC screening in resource constrained settings.
authors.affiliation: Arctic Investigations Program, Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Disease, U.S. Centers for Disease Control and Prevention (CDC), Anchorage, AK, USA; pgounder@cdc.gov.
authors.forename: Prabhu P
authors.initials: PP
authors.lastname: Gounder
authors.affiliation: Arctic Investigations Program, Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Disease, U.S. Centers for Disease Control and Prevention (CDC), Anchorage, AK, USA.
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Bulkow
authors.affiliation: Health Economics and Modeling Unit, Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Disease, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Martin I
authors.initials: MI
authors.lastname: Meltzer
authors.affiliation: Arctic Investigations Program, Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Disease, U.S. Centers for Disease Control and Prevention (CDC), Anchorage, AK, USA.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Bruce
authors.affiliation: Arctic Investigations Program, Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Disease, U.S. Centers for Disease Control and Prevention (CDC), Anchorage, AK, USA.
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Hennessy
authors.affiliation: Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, AK, USA.
authors.forename: Mary
authors.initials: M
authors.lastname: Snowball
authors.affiliation: Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Philip R
authors.initials: PR
authors.lastname: Spradling
authors.affiliation: Health Economics and Modeling Unit, Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Disease, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Bishwa B
authors.initials: BB
authors.lastname: Adhikari
authors.affiliation: Arctic Investigations Program, Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Disease, U.S. Centers for Disease Control and Prevention (CDC), Anchorage, AK, USA.|Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, AK, USA.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: McMahon
mesh_terms: D000328:Adult; D000072957:Alaska Natives; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000191:economics* / Q000378:metabolism; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000191:economics* / Q000378:metabolism; D008297:Male; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D014463:Ultrasonography / Q000191:economics; D000509:alpha-Fetoproteins / Q000032:analysis*
chemical_list: D000509:alpha-Fetoproteins
keywords: Alaska Native people; clinical outcome; diagnosis; early detection of cancer; economics