S1145 Current Hepatocellular Carcinoma Screening Strategies for Nonalcoholic Fatty Liver Disease May Not Be Cost-Effective

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INTRODUCTION: Nonalcoholic fatty liver disease (NAFLD), the leading cause of liver disease in the U.S., is associated with an increased risk of hepatocellular carcinoma (HCC), with ∼30% of NAFLD-associated HCC cases diagnosed in non-cirrhotic patients. HCC surveillance with twice-yearly (q6m) ultrasound (US) has been advocated for patients with stage 3 fibrosis (F3) and cirrhosis (F4). However, the cost-effectiveness (CE) of screening is unclear, particularly for F3 patients. Previous studies have found screening for F4 patients to be cost-effective, but they may have underestimated the costs associated with HCC treatment. We analyzed the CE of HCC screening in NAFLD incorporating recent HCC treatment cost data. METHODS: We created a novel microsimulation model of NAFLD and HCC natural history and surveillance. In a state-transition framework, 100,000 50-year-old patients progressed through the health states representing the development and growth of HCCs (with an annual HCC risk of 2.6% for F4, 0.02–0.9% for F3), screening for these tumors (comparing q6m US until age 70 to no screening), subsequent treatment, and long-term survival. Transition parameters were derived from published data. Each health state was associated with costs, with HCC treatment costing $130,240–$267,139 per a recent national VA study. We calculated incremental cost-effectiveness ratios (ICER) for several comparisons, determining acceptability of screening using a threshold of $100,000/life-year gained. We evaluated screening scenarios including q6m US for F3, F4 patients with follow-up of positive tests with MRI vs. CT, as well as q6m MRI for surveillance of F3 patients. RESULTS: The F4 NAFLD group screened with q6m US and followed up with MRI had an ICER of $178,270 with 3.2 average months of life gained. The F3 NAFLD group screened with q6m US (followed by MRI) had an ICER of $192,693 to $1,106,1878 and 0.07–2.3 months of life gained (for estimated annual HCC incidence of 0.02%–0.9%.) In the F3 NAFLD group screened with q6m MRI, the ICER was $289,375 with 1.3 months of life gained. CONCLUSION: We found that twice-yearly surveillance with US or MRI was associated with modest life-year gains for NAFLD patients with significant fibrosis, but surveillance was not cost-effective using contemporary willingness-to-pay thresholds. More individualized cost estimates based on HCC risk stratification, particularly among F3 patients, may be warranted.Table 1.: Cost-effectiveness analysis of HCC surveillance among F3 and F4 NAFLD patients by fibrosis stage and screening type