Cost-utility analysis of imaging for surveillance and diagnosis of hepatocellular carcinoma
Hepatocellular carcinoma (HCC) is a serious complication associated with chronic liver disease. Current guidelines recommended HCC surveillance using ultrasound (US) every six months. However, US surveillance can be challenging for some patients, particularly those with cirrhosis or obesity. Alternately, computed tomography (CT), magnetic resonance imaging (MRI), and abbreviated MRI have been explored as alternative imaging modalities and may be used in selected patients who are likely to have experienced inadequate US examinations. In this thesis, we aimed to assess the cost-effectiveness of imaging-based surveillance and diagnostic strategies in patients at risk of HCC while taking into account technically inadequate examinations and patients’ compliance. We compared seven surveillance and diagnostic strategies: strategy A, US for surveillance and CT for diagnosis; strategy B, US for surveillance and MRI for diagnosis; strategy C, US for surveillance and CT for inadequate or positive surveillance; strategy D, US for surveillance and MRI for inadequate or positive surveillance; strategy E, surveillance and diagnosis with CT followed by MRI for inadequate surveillance; strategy F, surveillance and diagnosis with MRI followed by CT for inadequate surveillance; and strategy G, surveillance with abbreviated MRI followed by CT for inadequate surveillance or MRI for positive surveillance. Two compliance scenarios were evaluated: optimal and conservative. For each scenario, the most cost-effective strategy was based on a willingness-to-pay threshold of Can$50,000 (Canadian dollars) per quality-adjusted life year (QALY). We also performed sensitivity analyses.  Our results demonstrated that strategy E was the most cost-effective strategy in scenarios with optimal patient compliance (Can$13,631/QALY). However, in scenarios with low patient compliance, strategy G was the most cost-effective alternative to the current US-surveillance practice (Can$39,681/QALY). Sensitivity analyses supported the base-case analysis in the optimal compliance scenario; however, several parameters altered the cost-effectiveness relationship in the conservative compliance scenario. By performing this economic analysis, we concluded that an individual approach, considering the clinical particularities of the patients, is more cost-effective than the current “one-size-fits-all” strategy. However, before implementing a surveillance program incorporating imaging modalities other than US, future studies should address the economic burden associated with false-positive HCC diagnoses and the accuracy of abbreviated MRI examinations in a surveillance setting.
Cost-effectiveness Early detection Liver cancer Liver imaging Markov model