Comparing the Cost-Effectiveness of Two Approaches to Hepatocellular Carcinoma (HCC) Surveillance in Persons with Chronic Hepatitis B (CHB) Virus Infection

Gounder, Prabhu

Comparing the Cost-Effectiveness of Two Approaches to Hepatocellular Carcinoma (HCC) Surveillance in Persons with Chronic Hepatitis B (CHB) Virus Infection

Monday, 18 August 2014: 11:15 AM

Tubughnenq 3 (Dena'ina Center)

Prabhu Gounder, MD , Centers for Disease Control and Prevention, Anchorage, AK

Lisa R Bulkow, MS , CDC Arctic Investigations Program, Anchorage, AK

Michael G Bruce, MD , CDC Arctic Investigations Program, Anchorage, AK

Thomas Hennessy, MD , CDC Arctic Investigations Program, Anchorage, AK

Mary Snowball , Alaska Native Tribal Health Consortium, Anchorage, AK

Bishwa Adhikari, PhD , Centers for Disease Control and Prevention, Atlanta, GA

Martin Meltzer, PhD , Centers for Disease Control and Prevention, Atlanta, GA

Philip Spradling, MD , Centers for Disease Control and Prevention, Atlanta, GA

Brian J McMahon, MD , Alaska Native Tribal Health Consortium, Anchorage, AK

INTRODUCTION: The American Association for the Study of Liver Diseases recommends HCC surveillance using ultrasound (US) for high risk (males >40, females >50 years) persons with CHB. We determined the cost/year of life gained (YLG) for semi-annual HCC screening by US-alone or alpha-fetoprotein (AFP) followed by US, if AFP is elevated (AFP-->US).

METHODS: We followed a cohort of Alaska Native (AN) persons with CHB with AFP every 6 months; persons at high-risk for HCC or persons with elevated AFP received US. We calculated person-years of follow-up until death or HCC diagnosis during 1983–2012. We calculated median survival by 3 HCC tumor sizes. We assumed 20% of tumors identified by AFP-->US at >6 cm would be identified by US-alone at <3 cm. We attributed to surveillance additional years of survival for persons with tumors <3 cm and 3-6 cm compared with tumors >6 cm. We calculated screening costs using 2012 Medicare reimbursement rates. We discounted costs and YLG at 3%. In sensitivity analyses, we determined the cost/YLG by US-alone assuming 0‒80% of tumors identified by AFP-->US at >6 cm were identified at <3 cm by US-alone.

RESULTS: We followed 839 persons for 10,405 person-years (median: 11 years/person) with 10,931 AFP measurements (median: 11/person). Among 21 persons with HCC, AFP-->US identified 4 at <3 cm and 6 at 3‒6 cm. AFP-->US yielded 26.5 YLG compared with 34.6 YLG by US-alone. AFP-->US cost $13,000/YLG compared with $24,000/YLG by US-alone. In sensitivity analyses, the cost/YLG by AFP-->US exceeded US-alone when 58% of tumors identified by AFP-->US at >6 cm were identified at <3 cm by US-alone.

CONCLUSIONS: HCC surveillance among AN persons with CHB by AFP-->US would potentially be more cost-effective than US-alone and could be considered in resource-limited settings. Health benefits from early detection by US-alone could be underestimated.