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HCC Incidence Threshold for Cost-Effective
Surveillance Much Lower Than Prior Standard
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AASLD, The Liver Meeting, November 12-15, 2021
Mark Mascolini
An hepatocellular carcinoma (HCC) incidence threshold of 0.4 cases per 100 person-years would make twice-a-year surveillance cost-effective in people with virologically cured HCV infection and cirrhosis, according to a microsimulation model [1]. That incidence threshold is well below the 1.5 cases per 100 person-years for people with HCV and cirrhosis in the days before direct-acting antivirals (DAAs) made sustained virologic response a reality in high proportions of people.
Although DAAs make virologic cure feasible for most people with HCV infection, HCC risk persists after DAA cure, and HCC contributes greatly to HCV-related morbidity and mortality in the DAA era. For people with HCV cirrhosis, current AASLD guidelines call for every-6-month HCC screening when HCC incidence-the new detection rate-exceeds 1.5 per 100 person-years [2].
HCC experts from Massachusetts General Hospital and other centers maintain that current cost-effectiveness studies used to calculate the HCC incidence threshold for surveillance guidance did not consider the lower competing risk now obvious in people cured of HCV infection, did not include new HCC treatment options, and used an old willingness-to-pay threshold to figure whether HCC screening is cost-effective.
To "estimate the HCC incidence above which routine HCC surveillance is cost-effective in virologically cured hepatitis C patients with cirrhosis," the researchers devised a microsimulation model of HCC natural history in people with cirrhosis and virologic cure of HCV through DAAs. The model accounted for contemporary realities of HCV and HCC management, including real-world adherence to HCC surveillance and new HCC treatment options and their costs. The HCC screening tools considered were ultrasound and alpha-fetoprotein. The model used an updated willingness-to-pay threshold of $100,000 per quality-adjusted life year .
Plugging these and other variables into the model, the researchers determined that the appropriate incidence threshold is 0.41 cases per 100 person-years, less than one third the previously accepted threshold of 1.5 cases per 100 person-years. The highest threshold the new modeling determined when considering the most sensitive parameter (monthly probability for medium to large HCC) was only 0.044 cases per 100 person-years. And the new HCC incidence threshold stayed lower than the current AASLD threshold regardless of uncertainty in model outcomes.
The modelers concluded that "HCC surveillance could be cost-effective if the annual incidence rate of HCC exceeds 0.4 per 100 person-years."
References
1. Chhatwal J, Hajjar A, Mueller PP, Nemutlu G, Peters MLB, Kanwal F. Hepatocellular carcinoma incidence threshold for routine surveillance is much lower in hepatitis C cirrhosis individuals who achieve virological cure. AASLD, The Liver Meeting, November 12-15, 2021. Parallel session 2: Health Services and Public Health.
2. Marrero JA, Kulik LM, Sirlin CB, et al. Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2018;68:723-750. doi: 10.1002/hep.29913. https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/hep.29913
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