An economic evaluation of routine hepatocellular carcinoma surveillance for high-risk patients using a novel approach to modelling competing risks

Joachim Worthington, Emily He, Michael Caruana, Stephen Wade, Barbara de Graaff, Anh Le Tuan Nguyen, Jacob George, Karen Canfell, Eleonora Feletto
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Abstract

Introduction: Liver cancer is the only cancer in Australia for which mortality rates have consistently risen, despite tests to identify high-risk individuals. Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer. Curative treatment for HCC is typically only available if detected early. Australian clinical guidelines recommend routine 6-monthly ultrasound surveillance, with or without serum alpha-fetoprotein, for individuals with liver cirrhosis. This study assesses the health and economic implications of this recommendation, utilizing novel modeling techniques. Methods: We designed the sojourn time density model mathematical framework to develop a model of the evolving risk of HCC, liver disease, and death based on time since diagnosis, incorporating data on liver decompensation, HCC incidence, and HCC survival, and the impact of surveillance on cancer stage and survival. Results: We estimated that adherence to 6-monthly ultrasound, with or without alpha-fetoprotein, can increase early-stage diagnosis rates, reducing HCC mortality by 22%. We estimate a cost-effectiveness ratio of $33,850 per quality-adjusted life-year (QALY) saved for 6-monthly ultrasound HCC surveillance, under the $50,000/QALY cost-effectiveness threshold. HCC surveillance was also estimated to be cost-effective at any interval from 3-24 months. Conclusions: These findings support the current clinical guideline recommendation for 6-monthly ultrasound surveillance, affirming its health benefits and cost-effectiveness, and show that alternative surveillance intervals would remain beneficial and cost-effective. Our model may be used to refine surveillance recommendations for other at-risk population subgroups and inform evidence-based clinical practice recommendations, and the framework can be adapted for other epidemiological modelling. Supporting the clinical guidelines and their ongoing development as evidence evolves may be key to reversing increasing HCC mortality rates in Australia, which are predicted to increase by more than 20% by 2040.
采用竞争风险建模新方法对高危患者肝细胞癌常规监测进行经济评估
导言:在澳大利亚,肝癌是唯一一种死亡率持续上升的癌症,尽管对高危人群进行了检测。肝细胞癌(HCC)是最常见的原发性肝癌。肝细胞癌通常只有在早期发现时才能得到根治性治疗。澳大利亚临床指南建议对肝硬化患者进行每 6 个月一次的常规超声监测,无论是否检测血清甲胎蛋白。本研究利用新型建模技术评估了这一建议对健康和经济的影响。方法:我们设计了停留时间密度模型数学框架,以建立一个基于诊断后时间的 HCC、肝病和死亡风险演变模型,其中纳入了肝脏失代偿、HCC 发病率和 HCC 存活率的数据,以及监测对癌症分期和存活率的影响。结果:我们估计,坚持每 6 个月进行一次超声波检查,无论是否进行甲胎蛋白检查,都能提高早期诊断率,将 HCC 死亡率降低 22%。我们估计,每6个月进行一次超声波HCC监测可节省33,850美元的质量调整生命年(QALY),低于50,000美元/QALY的成本效益阈值。据估计,在 3-24 个月的任何时间间隔内进行 HCC 监测都具有成本效益。结论:这些研究结果支持目前临床指南中关于每 6 个月进行一次超声波监测的建议,肯定了其健康益处和成本效益,并表明其他监测间隔仍然有益且具有成本效益。我们的模型可用于完善针对其他高危人群亚群的监测建议,并为循证临床实践建议提供依据,该框架还可用于其他流行病学建模。随着证据的不断发展,支持临床指南及其持续发展可能是扭转澳大利亚不断上升的HCC死亡率的关键,据预测,到2040年,澳大利亚的HCC死亡率将上升20%以上。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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