Posttransplant Hepatocellular Carcinoma Surveillance

Abstract

Objective: Assess cost-effectiveness and -utility associated with posttransplant HCC surveillance compared to standard follow-up. Summary of Background Data: Despite lack of prospective clinical data, expert consensus recommends posttransplant surveillance to detect HCC recurrence in a latent phase, while it might be amenable to curative-intent therapy. Methods: A Markov-based transition model was created to estimate life expectancy and quality-of-life among liver transplant patients undergoing HCC surveillance. Models were built for 2 cohorts: 1 undergoing HCC surveillance with contrast-enhanced computed tomography of chest and abdomen and serum alpha-fetoprotein analysis and the other receiving standard posttransplant follow-up. Primary model outputs included LY and QALY gains, incremental cost-effectiveness ratio, and incremental cost-utility ratio. Willingness-to-pay for a QALY gain (cost-effectiveness threshold) was used to estimate efficiency. Results: Surveillance was marginally more effective versus no surveillance, resulting in means of 0.069 LYs and 0.026 QALYs gained. Costs for surveillance were increased by an average of 988.32€, resulting in incremental cost-effectiveness ratio 14,410.15€/LY and incremental cost-utility ratio 37,547.97€/QALY. Surveillance did not seem cost-effective in our setting, considering willingness-to-pay threshold of 25,000€/QALY. Probabilistic sensitivity analysis indicated surveillance might be cost-effective in 42% of cases, but degree of uncertainty in the analysis was high. Conclusions: Performing posttransplant HCC surveillance offers marginal clinical benefits and increases costs. Although expert consensus supports surveillance, results of this decision analysis raise doubt regarding the utility of such recommendations and support ongoing need for prospective clinical trials.

European Society for Organ Transplantation Consensus Statement on Biomarkers in Liver Transplantation

“…Aside from the clear objective of improving candidate selection when applied in the pre-LT setting, a role for HCC molecular biomarkers in directing post-LT patient management is also discussed. Post-LT strategies that might be applied in high-risk patients include implementation of adjuvant systemic therapy/-ies and/or HCC surveillance protocols, though neither has been shown to be of clear clinical benefit [ 61 ]. As well, it is important to note that serial liquid biopsies performed during post-LT follow-up may create the complex and potentially distressing situation whereby HCC recurrence is “detected” (likely present) yet not located or visualized on cross-sectional imaging.…”