Cost-utility analysis of primary liver transplant versus salvage liver transplant after hepatectomy for hepatocellular carcinoma

Abstract

Background: Liver transplantation and hepatectomy remain the main curative therapies for hepatocellular carcinoma (HCC). Although transplant offers better disease-free survival than resection, the shortage of organs and current donor utilization policies limit its utilization in the setting HCC. Herein, we aim to determine the cost-utility between primary liver transplant (PLT) and salvage liver transplant (SLT) after resection for HCC. Methods: A Markov cohort model was created to simulate a cohort of 55-year-old patients, diagnosed with early-stage HCC within Milan criteria, eligible to undergo transplant or hepatectomy. The patients transitioned through different health states in 1-month cycles and were followed for a time horizon of 10 years. The primary outcome was quality-adjusted-life-years (QALY) gained. The ceiling ratio of US$100.000/QALY was adopted. Our analysis assumed the perspective of a third-party payer. Probabilities and utilities were obtained from literature review, and costs from Medicare database and Agency for Health Research and Quality. Results: The base-case analysis revealed SLT after hepatectomy for HCC as the dominant strategy. Primary liver transplant (PLT) had an incremental cost of US$ 535.530,00 when compared to SLT. In addition, it generated 0.23 QALYs less than SLT, therefore PLT was dominated. Sensitive analysis showed the most sensitive variables, that could affect the results of our analysis, were the rate of recurrence after hepatectomy and the probability of drop out while in the waiting list for SLT. When the recurrence rate after resection was more than 90% in 5-years (monthly rate > 4.2%), PLT was no longer dominated. Likewise, when the probability of drop out from the waiting list for SLT was more than 48% in 6 months (monthly probability > 10.3%), SLT was no longer dominated. On both scenarios the Incremental Cost-Effectiveness Ratio (ICER) was above the ceiling ratio of US$100.000/QALY, therefore SLT remained the more cost-effective strategy. Conclusion: In this study, Salvage Liver Transplant after Hepatectomy for HCC within Milan criteria was more cost-effective than Primary Liver Transplant.