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Abstract Details
Duration and cost-effectiveness of hepatocellular carcinoma surveillance in hepatitis C patients after viral eradication
J Hepatol. 2022 Jul;77(1):55-62. doi: 10.1016/j.jhep.2022.01.027. Epub 2022 Feb 12.
1Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
2Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA, USA.
3H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
4Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA, USA.
5Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
6Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, CA, USA.
7British Columbia Centre for Disease Control, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
8Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
9Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA, USA. Electronic address: jagchhatwal@mgh.harvard.edu.
Abstract
Background & aims: Successful treatment of chronic hepatitis C with oral direct-acting antivirals (DAAs) leads to virological cure, however, the subsequent risk of hepatocellular carcinoma (HCC) persists. Our objective was to evaluate the cost-effectiveness of biannual surveillance for HCC in patients cured of hepatitis C and the optimal age to stop surveillance.
Methods: We developed a microsimulation model of the natural history of HCC in individuals with hepatitis C and advanced fibrosis or cirrhosis who achieved virological cure with oral DAAs. We used published data on HCC incidence, tumor progression, real-world HCC surveillance adherence, and costs and utilities of different health states. We compared biannual HCC surveillance using ultrasound and alpha-fetoprotein for varying durations of surveillance (from 5 years to lifetime) vs. no surveillance.
Results: In virologically cured patients with cirrhosis, the incremental cost-effectiveness ratio (ICER) of biannual surveillance remained below $150,000 per additional quality-adjusted life year (QALY) (range: $79,500-$94,800) when surveillance was stopped at age 70, irrespective of the starting age (40-65). Compared with no surveillance, surveillance detected 130 additional HCCs in 'very early'/early stage and yielded 51 additional QALYs per 1,000 patients with cirrhosis. In virologically cured patients with advanced fibrosis, the ICER of biannual surveillance remained below $150,000/QALY (range: $124,600-$129,800) when surveillance was stopped at age 60, irrespective of the starting age (40-50). Compared with no surveillance, surveillance detected 24 additional HCCs in 'very early'/early stage and yielded 12 additional QALYs per 1,000 patients with advanced fibrosis.
Conclusion: Biannual surveillance for HCC in patients cured of hepatitis C is cost-effective until the age of 70 for patients with cirrhosis, and until the age of 60 for patients with stable advanced fibrosis.
Lay summary: Individuals who are cured of hepatitis C using oral antiviral drugs remain at risk of developing liver cancer. The value of lifelong screening for liver cancer in these individuals is not known. By simulating the life course of hepatitis C cured individuals, we found that ultrasound-based biannual screening for liver cancer is cost-effective up to age 70 in those with cirrhosis and up to age 60 in those with stable advanced fibrosis.