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Duration and cost-effectiveness of hepatocellular carcinoma surveillance in hepatitis C patients after viral eradication

  • Author Footnotes
    † Co-first authors.
    Peter P. Mueller
    Footnotes
    † Co-first authors.
    Affiliations
    Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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  • Author Footnotes
    † Co-first authors.
    Qiushi Chen
    Footnotes
    † Co-first authors.
    Affiliations
    Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA, USA
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  • Turgay Ayer
    Affiliations
    H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
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  • Gizem S. Nemutlu
    Affiliations
    Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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  • Ali Hajjar
    Affiliations
    Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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  • Emily D. Bethea
    Affiliations
    Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA, USA
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  • Mary Linton B. Peters
    Affiliations
    Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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  • Brian P. Lee
    Affiliations
    Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, CA, USA
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  • Naveed Z. Janjua
    Affiliations
    British Columbia Centre for Disease Control, Vancouver, BC, Canada

    School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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  • Author Footnotes
    ‡ Co-senior authors.
    Fasiha Kanwal
    Footnotes
    ‡ Co-senior authors.
    Affiliations
    Department of Medicine, Baylor College of Medicine, Houston, TX, USA

    Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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  • Author Footnotes
    ‡ Co-senior authors.
    Jagpreet Chhatwal
    Correspondence
    Corresponding author. Address: MGH Institute for Technology Assessment, 101 Merrimac Street, Ste 1010, Boston, MA 02114, USA; Tel.: (617) 724-4445, fax: (617) 726-9414.
    Footnotes
    ‡ Co-senior authors.
    Affiliations
    Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA, USA
    Search for articles by this author
  • Author Footnotes
    † Co-first authors.
    ‡ Co-senior authors.
Published:February 11, 2022DOI:https://doi.org/10.1016/j.jhep.2022.01.027

      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

      Keywords

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