The cost-effectiveness of transarterial chemoembolization treatments.

Abstract

e14626 Background: Transarterial chemoembolization (TACE) is often a treatment for patients precluded from surgery. TACE recipients may get ≥1 TACE treatment, yet little is known about the cost-effectiveness of such additional TACEs. Methods: The study population includes 1,095 Medicare patients with a 1st diagnosis of 1ry HCC in 2000-07 who got TACE, or both TACE+ablation (LD) where one occurred prior to any other treatments. Patients were studied through end of 2009, in SEER-Medicare A-B. Stratifying by ablation, Cox proportional hazards models were built to assess the impacts of successive TACEs on all-cause/HCC-mortality, adjusting for clinical (cancer stage, underlying health status, liver conditions) and demographics. Average HCC-related Medicare costs (US$2,011) attributed to additional TACEs was estimated with generalized least squares, obtaining incremental cost effectiveness ratios (ICERs) and 95% confidence intervals, controlling for systemic chemotherapy and radiation therapy in the follow-up period. Results: Cancer stages 1, 2, 3, and 4 represented 34%, 16%, 19%, and 5% of the 1095 patients, respectively: 26% unstaged, 68% male, 71% Caucasian, 6% African American, and 17% Hispanic. 474 non-LD TACE patients had one TACE, 218 two, 93 three, 70 ≥four. Among LD patients, 121 got 1 TACE, 58 two, 34 three, 27 ≥four. In non-LD patients, further reductions in all-cause/HCC mortality were associated with the 2nd (HR .76, p<.01; HR .78, p=.045) and 3rd (HR .68, p<.01; HR .61, p<.01) TACE, but not the 4th; only the 3rd TACE further reduced mortality risk in LD patients (HR .48, p=.01; HR .34, p .01). For non-LD patients, using HCC mortality, the 2nd TACE was attributed to $19,969 per life year (LY) added, 95%CI $8,634, $31,303, the 3rd $10,290/LY ($2,815, $17,764); using all-cause mortality, the 2nd $27,813/LY ($15,943, $39,684), the 3rd ICER was statistically N.S. All ICERs were N.S. for LD patients. Conclusions: Additional TACEs provide survival benefit for HCC Medicare patients in clinical practice. However, that benefit may decrease after the 3rd exposure, which is more cost effective than a 2nd one. Additional TACEs may be confounded if ≥4 TACEs are intended to treat biologically aggressive disease.