背景:肝细胞癌(HCC)是澳大利亚癌症死亡增加最快的原因。最近的澳大利亚共识指南建议肝硬化患者和非肝硬化慢性乙型肝炎(CHB)患者在性别和年龄特定的截止日期进行HCC监测。然后开发了成本效益模型来评估澳大利亚的监测策略。
方法:使用微观模拟模型来评估三种策略:一年两次的超声,一年两次的超声与甲胎蛋白(AFP)和没有正式的监测患者的条件之一:非肝硬化CHB,代偿期肝硬化或失代偿期肝硬化。单向和概率敏感性分析以及情景和阈值分析进行了考虑不确定性:包括CHB的独家监测,代偿期肝硬化或失代偿期肝硬化人群;肥胖对超声敏感性的影响;真实世界的依从率;和不同的队列年龄范围。
结果:基线人群考虑了60种HCC监测方案。超声+AFP策略是最具成本效益的增量成本效益比(ICER),而在所有年龄段,没有监测低于支付意愿阈值,即每质量调整生命年(QALY)50,000澳元。仅超声也具有成本效益,但该策略以超声+AFP为主。仅在补偿和失代偿肝硬化人群中,监测具有成本效益(ICERs<30,000美元),但在CHB人群中没有成本效益(ICER>100,000美元)。肥胖会降低超声的诊断性能,反过来,降低超声±AFP的成本效益,但是这些策略仍然具有成本效益。
结论:根据澳大利亚建议使用两年一次的超声±AFP进行HCC监测具有成本效益。
BACKGROUND: Hepatocellular carcinoma (HCC) is the fastest increasing cause of cancer death in Australia. A recent Australian
consensus guidelines recommended HCC surveillance for cirrhotic patients and non-cirrhotic chronic hepatitis B (CHB) patients at gender and age specific cut-offs. A cost-effectiveness model was then developed to assess surveillance strategies in Australia.
METHODS: A microsimulation model was used to evaluate three strategies: biannual ultrasound, biannual ultrasound with alpha-fetoprotein (AFP) and no formal surveillance for patients having one of the conditions: non-cirrhotic CHB, compensated cirrhosis or decompensated cirrhosis. One-way and probabilistic sensitivity analyses as well as scenario and threshold analyses were conducted to account for uncertainties: including exclusive surveillance of CHB, compensated cirrhosis or decompensated cirrhosis populations; impact of obesity on ultrasound sensitivity; real-world adherence rate; and different cohort\'s ranges of ages.
RESULTS: Sixty HCC surveillance scenarios were considered for the baseline population. The ultrasound + AFP strategy was the most cost-effective with incremental cost-effectiveness ratios (ICER) compared to no surveillance falling below the willingness-to-pay threshold of A$50,000 per quality-adjusted life year (QALY) at all age ranges. Ultrasound alone was also cost-effective, but the strategy was dominated by ultrasound + AFP. Surveillance was cost-effective in the compensated and decompensated cirrhosis populations alone (ICERs < $30,000), but not cost-effective in the CHB population (ICERs > $100,000). Obesity could decrease the diagnostic performance of ultrasound, which in turn, reduce the cost-effectiveness of ultrasound ± AFP, but the strategies remained cost-effective.
CONCLUSIONS: HCC surveillance based on Australian recommendations using biannual ultrasound ± AFP was cost-effective.