CT diagnosis and surveillance of hepatocellular carcinoma (HCC) is the most cost-effective imaging-based strategy when patients are fully compliant, according to an April 17 study published in the American Journal of Roentgenology.
“Costs attributable to HCC account for a substantial financial burden, are higher when HCC is diagnosed at advanced stages, and are expected to increase until the HCC incidence reaches its peak,” wrote Paulo Henrique Lima, Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada, and colleagues. “Given that health care systems are limited in their financial resources, competing surveillance strategies should be analyzed for their cost-effectiveness.”
The researchers used a Markov model to simulate seven strategies for HCC surveillance and diagnosis in patients with cirrhosis. Lima and colleagues evaluated optimal and conservative compliance scenarios along with inadequate exams, which previous research has failed to take into account, the authors noted.
North American guidelines currently recommend ultrasound (US) surveillance every six months in patients at risk for HCC. However, HCC surveillance compliance is “suboptimal,” according to the researchers, with an overall rate of 52%.
In each scenario cost-effectiveness was based on a willingness-to-pay threshold of 50,000 Canadian dollars ($37,456) per quality-adjusted life year (QALY).
When compliance was optimal the most cost-effective strategy was surveillance and diagnosis with CT followed by complete MRI for inadequate surveillance (CA$13,631/QALY), or strategy E. When compliance was conservative, the best option was surveillance with abbreviated MRI followed by CT for inadequate surveillance or complete MRI for positive surveillance (CA$39,681/QALY)—strategy G.
According to Lima et al. strategies that rely solely on a single exam for surveillance and diagnosis—such as strategy E—are more susceptible to higher rates of false-positive diagnoses. In such a case, healthy patients may be exposed to psychologic stress and risks that may drive up their costs. Therefore, such strategies must be carefully considered.
“Before implementing a surveillance program incorporating imaging modalities other than ultrasound, future studies should address the economic burden associated with false-positive HCC diagnoses. Also, future prospective trials should assess the accuracy of abbreviated MRI examinations in a surveillance setting,” the authors concluded.