Cost-effectiveness analysis of treatment with non-curative or palliative intent for hepatocellular carcinoma in the real-world setting

Abstract

Hepatocellular carcinoma (HCC) presentation is heterogeneous necessitating a variety of therapeutic interventions with varying efficacies and associated prognoses. Poor prognostic patients often undergo non-curative palliative interventions including transarterial chemoembolization (TACE), sorafenib, chemotherapy, or purely supportive care. The decision to pursue one of many palliative interventions for HCC is complex and an economic evaluation comparing these interventions has not been done. This study evaluates the cost-effectiveness of non-curative palliative treatment strategies such as TACE alone or TACE+sorafenib, sorafenib alone, and non-sorafenib chemotherapy compared with no treatment or best supportive care (BSC) among patients diagnosed with HCC between 2007 and 2010 in a Canadian setting. Using person-level data, we estimated effectiveness in life years and quality-adjusted life years (QALYs) along with total health care costs (2013 US dollars) from the health care payer’s perspective (3% annual discount). A net benefit regression approach accounting for baseline covariates with propensity score adjustment was used to calculate incremental net benefit to generate incremental cost-effectiveness ratio (ICER) and uncertainty measures. Among 1,172 identified patients diagnosed with HCC, 4.5%, 7.9%, and 5.6%, received TACE alone or TACE+sorafenib, sorafenib, and non-sorafenib chemotherapy clone, respectively. Compared with no treatment or BSC (81.9%), ICER estimates for TACE alone or TACE+sorafenib was $6,665/QALY (additional QALY: 0.47, additional cost: $3,120; 95% CI: -$18,800-$34,500/QALY). The cost-effectiveness acceptability curve demonstrated that if the relevant threshold was $50,000/QALY, TACE alone or TACE+sorafenib, non-sorafenib chemotherapy, and sorafenib alone, would have a cost-effectiveness probability of 99.7%, 46.6%, and 5.5%, respectively. Covariates associated with the incremental net benefit of treatments are age, sex, comorbidity, and cancer stage. Findings suggest that TACE with or without sorafenib is currently the most cost-effective active non-curative palliative treatment approach to HCC. Further research into new combination treatment strategies that afford the best tumor response is needed.

The role of external beam radiotherapy in the treatment of hepatocellular cancer

“…89 A similar study by the same group comparing noncurative palliative interventions, including TACE, sorafenib, chemotherapy, or purely supportive care, reported that TACE with or without sorafenib was the most cost-effective palliative treatment at $6665 per QALY. 90 A Monte-Carlo model study from Taiwan comparing sorafenib with HIGRT indicated that HIGRT was the most cost-effective treatment and was aligned with the current accepted QALY threshold in Taiwan (approximately $67K [in US dollars] per QALY). 91 A US-based Markov model study comparing RFA with HIGRT treatment sequencing (assuming locally progressive disease after RFA or HIGRT requiring second treatment and a threshold of $100K per QALY) demonstrated that RFA was the most cost-effective initial treatment and that HIGRT was the preferred salvage treatment for locally recurrent disease.…”

Minimally invasive therapies for hepatocellular carcinoma: narrowing the gaps

“…Based on Markov modelling, it has been suggested that RFA is more cost-effective than SBRT as the initial management of unresectable HCC, however, for recurrent disease, SBRT was favored over repeat RFA [74] . Another study demonstrated that the addition of TACE to sorafenib or non-sorafenib chemotherapy is more cost effective than systemic therapy alone [75] . As the financial burden rises, some resources may become limiting, and physicians and their patients will need to have open discussions regarding the wise utilization of available options that meet their personal goals.…”

EPDR1 correlates with immune cell infiltration in hepatocellular carcinoma and can be used as a prognostic biomarker

“…Currently, the diagnosis of HCC is mainly based on the detection of serum alphafetoprotein (AFP), B-ultrasound, and computed tomography imaging. However, the misdiagnosis and missed diagnosis rates are very high [6][7][8]. Owing to the insidious onset, poor tumor biological behavior, and rapid progress of HCC, most patients reach advanced stage of the disease and miss the opportunity for radical treatment.…”