Abstract

Hepatocellular carcinoma (HCC) presentation is heterogeneous necessitating a variety of therapeutic interventions with varying efficacies and associated prognoses. Poor prognostic patients often undergo non-curative palliative interventions including transarterial chemoembolization (TACE), sorafenib, chemotherapy, or purely supportive care. The decision to pursue one of many palliative interventions for HCC is complex and an economic evaluation comparing these interventions has not been done. This study evaluates the cost-effectiveness of non-curative palliative treatment strategies such as TACE alone or TACE+sorafenib, sorafenib alone, and non-sorafenib chemotherapy compared with no treatment or best supportive care (BSC) among patients diagnosed with HCC between 2007 and 2010 in a Canadian setting. Using person-level data, we estimated effectiveness in life years and quality-adjusted life years (QALYs) along with total health care costs (2013 US dollars) from the health care payer’s perspective (3% annual discount). A net benefit regression approach accounting for baseline covariates with propensity score adjustment was used to calculate incremental net benefit to generate incremental cost-effectiveness ratio (ICER) and uncertainty measures. Among 1,172 identified patients diagnosed with HCC, 4.5%, 7.9%, and 5.6%, received TACE alone or TACE+sorafenib, sorafenib, and non-sorafenib chemotherapy clone, respectively. Compared with no treatment or BSC (81.9%), ICER estimates for TACE alone or TACE+sorafenib was $6,665/QALY (additional QALY: 0.47, additional cost: $3,120; 95% CI: -$18,800-$34,500/QALY). The cost-effectiveness acceptability curve demonstrated that if the relevant threshold was $50,000/QALY, TACE alone or TACE+sorafenib, non-sorafenib chemotherapy, and sorafenib alone, would have a cost-effectiveness probability of 99.7%, 46.6%, and 5.5%, respectively. Covariates associated with the incremental net benefit of treatments are age, sex, comorbidity, and cancer stage. Findings suggest that TACE with or without sorafenib is currently the most cost-effective active non-curative palliative treatment approach to HCC. Further research into new combination treatment strategies that afford the best tumor response is needed.

Highlights

  • Liver cancer is the sixth most common cancer and the second leading cause of cancer-related death worldwide [1]

  • We aim to evaluate the cost-effectiveness of alternative non-curative palliative treatment interventions of Transarterial chemoembolization (TACE) alone or TACE+sorafenib, sorafenib alone, and non-sorafenib chemotherapy alone compared with no treatment or best supportive care (BSC) using person-level data from the Canadian health care perspective

  • A representative flow chart of the study population can be found in S1 Fig. The final study cohort comprised 1,172 patients diagnosed with hepatocellular carcinoma (HCC) after excluding patients who had curative treatments and relatively small number of noncurative palliative treatments

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Summary

Introduction

Liver cancer is the sixth most common cancer and the second leading cause of cancer-related death worldwide [1]. Transarterial chemoembolization (TACE) is the standard of care for patients with intermediate-stage disease [5,6], and survival times and time to progression appear longer in patients with the combination of sorafenib and TACE [7,8,9]. Studies using data from the SHARP trial [10] determined that sorafenib is cost-effective compared to best supportive care (BSC) with an incremental cost-effectiveness ratio (ICER) within the established willingness-to-pay threshold between $50,000 and $100,000/life year (LY) gained [13,14]. The Italian SOFIA study concluded that dose-adjusted sorafenib is cost-effective compared to BSC in intermediate and advanced HCC with an ICER of less than a threshold of €38,000/quality-adjusted life year (QALY) gained (~$50,000/QALY) [15]. Another study found that sorafenib is not a cost-effective treatment option for Chinese patients with advanced HCC [16]

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