Cost-effectiveness of Surveillance
An intervention is considered effective if it provides an increase in longevity of about 100 days (i.e., about 3 months). Although the levels were set years ago, and may not be appropriate today, interventions that can be achieved at a cost of less than about $50,000/year of life gained are considered cost-effective. There are now several published decision analysis/cost-efficacy models for hepatocellular carcinoma (HCC) surveillance. The models differ in the nature of the theoretical population being analyzed, and in the intervention being applied. Nonetheless, these models have several results in common. They all find that surveillance is cost-effective, although in some cases only marginally so, and most find that the efficacy of surveillance is highly dependent on the incidence of HCC. (Refer to the original guideline document for a short description of these models). Thus, for patients with cirrhosis of varying etiologies, surveillance should be offered when the risk of HCC is 1.5%/year or greater. A table in the "Major Recommendations" section of this summary (Table 3 in the original guideline document) describes the groups of patients in which these limits are exceeded. These groups of patients are also discussed in more detail in the original guideline document. These cost-efficacy analyses was restricted to cirrhotic populations.
The above cost-efficacy analyses, which were restricted to cirrhotic populations, cannot be applied to hepatitis B carriers without cirrhosis. These patients, particularly in Asia and Africa, are also at risk for HCC. A cost-efficacy analysis of surveillance of hepatitis B carriers using ultrasound and alpha-fetoprotein (AFP) levels suggested that surveillance became cost-effective once the incidence of HCC exceeded 0.2%/year.
It would seem to be in a patient's interest to have a small HCC diagnosed while on the liver transplant waiting list. One cost-efficacy analysis has suggested that the increase in longevity over the whole cohort of patients awaiting transplant is negligible, because although there may be an increase in longevity in those who develop HCC, it is countered by the loss of longevity in other patients on the waiting list whose transplants are delayed so that the patient with HCC can have priority. In contrast, identification of HCC that exceeds guidelines, and resultant de-listing of such patients, is beneficial to other patients on the waiting list. Another analysis suggested that there were benefits to treating patients with HCC on the transplant waiting list with either resection or local ablation. The benefit depended in part on the length of the waiting list. The longer the wait, the greater the benefit of intervention.
Combined use of AFP and ultrasonography increases detection rates, but also increases costs and false-positive rates. AFP-only surveillance had a 5.0% false-positive rate, ultrasound alone had a 2.9% false-positive rate, but in combination the false-positive rate was 7.5%. Ultrasound alone cost about $2000 per tumor found, whereas the combination cost about $3000 per tumor found.
Priority Listing for Transplantation
Patients with small tumors can have ablation either by percutaneous ethanol injection, radiofrequency or any other technique and statistical modeling has shown that such intervention is cost-effective if the expected waiting time is longer than 6 months.
Living Donor Orthotopic Transplantation
This is especially relevant for patients with hepatitis C virus infection in whom the potential severe recurrent liver disease is a matter of controversy. Decision analysis taking into account the risk of drop-out while waiting (4% per month), the expected survival of the recipient (70% at 5 years) and the risk for the donor (0.3%-0.5% mortality) suggest that this is a cost-effective approach if the waiting time exceeds 7 months.
