Highlights
- •The value of lifelong surveillance for HCC in individuals after SVR is not known.
- •Ultrasound-based bi-annual surveillance for HCC appears to be cost-effective up to age 75 in those with cirrhosis.
- •This surveillance strategy was cost effective up to age 60 in those with stable advanced fibrosis.
- •Compared with no surveillance, surveillance detected 86 additional HCCs in ‘very early’/early stage per 1,000 patients with cirrhosis.
Background & Aims
Successful treatment of chronic hepatitis C with oral direct-acting antivirals (DAAs)
leads to virological cure, however, the subsequent risk of hepatocellular carcinoma
(HCC) persists. Our objective was to evaluate the cost-effectiveness of biannual surveillance
for HCC in patients cured of hepatitis C and the optimal age to stop surveillance.
Methods
We developed a microsimulation model of the natural history of HCC in individuals
with hepatitis C and advanced fibrosis or cirrhosis who achieved virological cure
with oral DAAs. We used published data on HCC incidence, tumor progression, real-world
HCC surveillance adherence, and costs and utilities of different health states. We
compared biannual HCC surveillance using ultrasound and alpha-fetoprotein for varying
durations of surveillance (from 5 years to lifetime) vs. no surveillance.
Results
In virologically cured patients with cirrhosis, the incremental cost-effectiveness
ratio (ICER) of biannual surveillance remained below $150,000 per additional quality-adjusted
life year (QALY) (range: $79,500-$94,800) when surveillance was stopped at age 70,
irrespective of the starting age (40-65). Compared with no surveillance, surveillance
detected 130 additional HCCs in ‘very early’/early stage and yielded 51 additional
QALYs per 1,000 patients with cirrhosis. In virologically cured patients with advanced
fibrosis, the ICER of biannual surveillance remained below $150,000/QALY (range: $124,600-$129,800)
when surveillance was stopped at age 60, irrespective of the starting age (40-50).
Compared with no surveillance, surveillance detected 24 additional HCCs in ‘very early’/early
stage and yielded 12 additional QALYs per 1,000 patients with advanced fibrosis.
Conclusion
Biannual surveillance for HCC in patients cured of hepatitis C is cost-effective until
the age of 70 for patients with cirrhosis, and until the age of 60 for patients with
stable advanced fibrosis.
Lay summary
Individuals who are cured of hepatitis C using oral antiviral drugs remain at risk
of developing liver cancer. The value of lifelong screening for liver cancer in these
individuals is not known. By simulating the life course of hepatitis C cured individuals,
we found that ultrasound-based biannual screening for liver cancer is cost-effective
up to age 70 in those with cirrhosis and up to age 60 in those with stable advanced
fibrosis.
Graphical abstract
Graphical Abstract
Keywords
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Article info
Publication history
Published online: February 11, 2022
Accepted:
January 28,
2022
Received in revised form:
January 13,
2022
Received:
March 26,
2021
Footnotes
Author names in bold designate shared co-first authorship
Identification
Copyright
© 2022 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
