MT4 The Cost-Effectiveness of Selective Internal Radiation Therapy (SIRT) for Treating Advanced Unresectable Hepatocellular Carcinoma in the United Kingdom

Abstract

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. Approximately 50% of European patients are diagnosed with advanced stage disease (BCLC stage C), which in the UK is currently treated using systemic agents such as sorafenib and lenvatinib. Selective internal radiation therapies (SIRT) offer an alternative approach to treatment, delivering radiation directly to liver tumours via microspheres injected into the hepatic artery. The National Institute for Health and Clinical Excellence (NICE) sought to assess the clinical- and cost-effectiveness of three SIRT technologies: TheraSphere®, SIR-Spheres®, and QuiremSpheres® for use in the UK. The project aimed to assess the clinical and cost-effectiveness of SIRT technologies for treating patients with advanced unresectable HCC on behalf of NICE. Systematic searches were undertaken to identify relevant clinical effectiveness literature. Estimates of the relative effectiveness of the different treatments were generated using network meta-analysis (NMA). An economic model was built to evaluate the cost-effectiveness of SIRT. The outcome of the work-up procedure was captured using a decision tree which fed into a three-state partitioned survival model. The NMA showed no meaningful differences in overall survival between any of the treatments. In the base-case economic analysis, SIRT generated fewer QALYs than sorafenib or lenvatinib, but was associated with higher costs. In the fully incremental analysis considered by the NICE Technology Appraisal Committee, including confidential discounts, lenvatinib was the most cost-effective and dominated SIRT. Sorafenib also dominated each SIRT in pairwise comparisons. Scenario analyses showed that SIRT was more likely to be cost-effective in a subgroup of patients with low tumour burden and good liver function, and when downstaging to transplant was possible. In advanced HCC, SIRT has similar effectiveness to sorafenib and is not cost-effective. Some subgroups may offer the potential for cost-effective treatment, but certainty in available evidence was insufficient for decision making.