Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, New York, NY, United States of America.
VA Connecticut-Healthcare System, West Haven, CT, United States of America.
PLoS One. 2019 Aug 26;14(8):e0221614. doi: 10.1371/journal.pone.0221614. eCollection 2019.
Hepatocelluar cancer (HCC) is the leading cause of death among people with hepatitis C virus (HCV)-related cirrhosis. Our aim was to determine the optimal surveillance frequency for patients with HCV-related compensated cirrhosis.
We developed a decision analytic Markov model and validated it against data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) study group and published epidemiologic studies. Four strategies of different surveillance intervals were compared: no surveillance and ultrasound surveillance every 12, 6, and 3 months. We estimated lifetime survival, life expectancy, quality adjusted life years (QALY), total costs associated with each strategy, and incremental cost effectiveness ratios. We applied a willingness to pay threshold of $100,000. Analysis was conducted for two scenarios: a scenario reflecting current HCV and HCC surveillance compliance rates and treatment use and an aspirational scenario.
In the current scenario the preferred strategy was 3-month surveillance with an incremental cost-effectiveness ratio (ICER) of $7,159/QALY. In the aspirational scenario, 6-month surveillance was preferred with an ICER of $82,807/QALY because treating more people with HCV led to a lower incidence of HCC. Sensitivity analyses suggested that surveillance every 12 months would suffice in the particular circumstance when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available. Compared with the current scenario, the aspirational scenario resulted in a 1.87 year gain in life expectancy for the cohort because of large reductions in decompensated cirrhosis and HCC incidence.
HCC surveillance has good value for money for patients with HCV-related compensated cirrhosis. Investments to improve adherence to surveillance should be made when rates are suboptimal. Surveillance every 12 months will suffice when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available.
肝细胞癌（HCC）是丙型肝炎病毒（HCV）相关肝硬化患者死亡的主要原因。我们的目的是确定 HCV 相关代偿性肝硬化患者的最佳监测频率。
我们开发了一个决策分析马尔可夫模型，并使用 Veterans Outcomes and Costs Associated with Liver Disease（VOCAL）研究组和已发表的流行病学研究的数据对其进行了验证。比较了四种不同监测间隔的策略：不监测和超声监测每 12、6 和 3 个月一次。我们估计了每种策略的终生生存率、预期寿命、质量调整生命年（QALY）、与每种策略相关的总费用以及增量成本效益比。我们应用了 10 万美元的支付意愿阈值。分析了两种情况：反映当前 HCV 和 HCC 监测依从率和治疗使用率的情况和理想情况。
在当前情况下，首选策略是每 3 个月监测一次，增量成本效益比（ICER）为 7159 美元/QALY。在理想情况下，首选每 6 个月监测一次，ICER 为 82807 美元/QALY，因为治疗更多的 HCV 患者导致 HCC 发病率降低。敏感性分析表明，在患者非常有可能定期返回进行检测并且适当的 HCV 和 HCC 治疗随时可用的特定情况下，每年监测一次就足够了。与当前情况相比，由于失代偿性肝硬化和 HCC 发病率大幅降低，理想情况下该队列的预期寿命增加了 1.87 年。
对于 HCV 相关代偿性肝硬化患者，HCC 监测具有良好的性价比。当监测率不理想时，应投资提高对监测的依从性。当患者非常有可能定期返回进行检测并且适当的 HCV 和 HCC 治疗随时可用时，每年监测一次就足够了。
