Cost effectiveness of adjuvant therapy for hepatocellular carcinoma during the waiting list for liver transplantation

Abstract

Background: Survival after liver transplantation for early hepatocellular carcinoma (HCC) is worsened by the increasing dropout rate while waiting for a donor. Aims: To assess the cost effectiveness of adjuvant therapy while waiting for liver transplantation in HCC patients. Method: Using a Markov model, a hypothetical cohort of cirrhotic patients with early HCC was considered for: (1) adjuvant treatment-resection was limited to Child-Pugh's A patients with single tumours, and percutaneous treatment was considered for Child-Pugh's A and B patients with single tumours unsuitable for resection or with up to three nodules < 3 cm; and (2) standard management. Length of waiting time ranged from six to 24 months. Results: Surgical resection increased the transplantation rate (>10%) and provided gains in life expectancy of 4.8-6.1 months with an acceptable cost ($40 000/ year of life gained) for waiting lists >1 year whereas it was not cost effective ($74 000/life of year gained) for shorter waiting times or high dropout rate scenarios. Percutaneous treatment increased life expectancy by 5.2-6.7 months with a marginal cost of approximately $20 000/year of life gained in all cases, remaining cost effective for all waiting times. Conclusions: Adjuvant therapies for HCC while waiting for liver transplantation provide moderate gains in life expectancy and are cost effective for waiting lists of one year or more. For shorter waiting times, only percutaneous treatment confers a relevant survival advantage.

Surveillance of cirrhosis for hepatocellular carcinoma: systematic review and economic analysis

“…243 Increasingly, techniques such as those described above are being used with the aim of delaying tumour progression in patients awaiting OLT (neoadjuvant or bridging therapy). 244 This approach has not been assessed in any randomised trials; however, some observational [245][246][247][248] and modelling 228,249 studies have suggested that it may assist in waiting list management, thereby maximising the effectiveness of an OLT programme. It has been emphasised that, although bridging strategies may induce objectively demonstrable pretransplant tumour control, this apparent effectiveness may not ultimately be reflected in survival benefit following OLT.…”

Is the treatment of hepatocellular carcinoma on the waiting list necessary?

“…20 Two decision analysis studies found a treatment advantage based on the waiting time and the type of treatment. 21,22 The first study (from the BCLC group) 21 compared resection, percutaneous ethanol injection (PEI), and no treatment in a scenario in which the dropout rate without treatment was 10% at 22 analyzed TACE versus no treatment in T2 patients and assumed a TACE response rate of 30% and a tumor progression rate of 7% per month. The TACE treatment had a statistical benefit at the waitlist time breakpoints of 4 and 9 months (P < 0.05).…”

Role of Liver Transplantation for Hepatocellular Carcinoma

“…31 Liver resection was considered only in Childs-Pugh A patients while percutaneous treatment was considered for B patients as well. Surgical resection increased the transplantation rate by more than 10% and increased the life-expectancy by 4.8-6.1 months at a cost of $40,000/-per life year gained if the waiting time was more than 1 year.…”