An economic evaluation of routine hepatocellular carcinoma surveillance for high-risk patients using a novel approach to modelling competing risks

Abstract

Introduction: Liver cancer is the only cancer in Australia for which mortality rates have consistently risen, despite tests to identify high-risk individuals. Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer. Curative treatment for HCC is typically only available if detected early. Australian clinical guidelines recommend routine 6-monthly ultrasound surveillance, with or without serum alpha-fetoprotein, for individuals with liver cirrhosis. This study assesses the health and economic implications of this recommendation, utilizing novel modeling techniques. Methods: We designed the sojourn time density model mathematical framework to develop a model of the evolving risk of HCC, liver disease, and death based on time since diagnosis, incorporating data on liver decompensation, HCC incidence, and HCC survival, and the impact of surveillance on cancer stage and survival. Results: We estimated that adherence to 6-monthly ultrasound, with or without alpha-fetoprotein, can increase early-stage diagnosis rates, reducing HCC mortality by 22%. We estimate a cost-effectiveness ratio of $33,850 per quality-adjusted life-year (QALY) saved for 6-monthly ultrasound HCC surveillance, under the $50,000/QALY cost-effectiveness threshold. HCC surveillance was also estimated to be cost-effective at any interval from 3-24 months. Conclusions: These findings support the current clinical guideline recommendation for 6-monthly ultrasound surveillance, affirming its health benefits and cost-effectiveness, and show that alternative surveillance intervals would remain beneficial and cost-effective. Our model may be used to refine surveillance recommendations for other at-risk population subgroups and inform evidence-based clinical practice recommendations, and the framework can be adapted for other epidemiological modelling. Supporting the clinical guidelines and their ongoing development as evidence evolves may be key to reversing increasing HCC mortality rates in Australia, which are predicted to increase by more than 20% by 2040.