Method: Main medical databases were searched for any published cost-effectiveness analyses assessing image-based methods for HCC screening in cirrhotic patients. Qualified studies were reviewed to extract information on screening methods, screening population characteristics, model structure, model variables, and study results. Single arm meta-analysis was performed to demonstrate uncertainty associated with model variables. The reported incremental cost-effectiveness ratios (ICER) per gained quality adjusted life year (QALY) associated with screening strategies were adjusted to current value and presented in ratio to 2012 gross domestic product (GDP) per capita for the country the cost-effectiveness analysis was based on. Univariate linear regression analysis taking ICER per gained QALY as dependent variable was performed to assess the association between model variables and the cost-effectiveness of HCC screening.
Result: Twelve studies were identified to investigate the cost-effectiveness of HCC screening in cirrhotic patients using ultrasound (US), alpha-fetoprotein (AFP), contrast-enhanced ultrasound (CEUS), computed tomography (CT), or magnetic resonance imaging (MRI) with screening frequency of 3 to 12 months in 8 countries. Single arm meta-analysis identified significant uncertainty associated with specificity and sensitivity of CEUS for small HCC detection (< 3 cm) and annual transition probability from small to large size of HCC after transarterial embolization treatment. Base case ICER per gained life year associated with US per 6 months (0.16 GDP per capita), CEUS per 6 months (0.17 GDP per capita), US plus AFP per a year (0.54 GDP per capita), CT plus AFP per 6 months (0.60 GDP per capita), US plus AFP per 6 months (0.63 GDP per capital) were less than 1 GDP per captia when compared to no screening. Univariate linear regression analysis indicated that the cost-effectiveness of HCC screening was significantly reduced when screening frequency was 6 months (coefficient 1.919, p=0.002). HCC recurrence had the strongest association with the cost-effectiveness of HCC screening but the association was not statistically significant due to small number of included studies (coefficient 41.899, p=0.357).
Conclusion: Screening cirrhotic patients for HCC with US every 6 months is the most cost-effective strategy according to current economic evidence. Preventing HCC recurrence could substantially improve the cost-effectiveness of HCC screening in cirrhotic patients.