Ultrasound Elastography for Fibrosis Surveillance Is Cost Effective in Patients with Chronic Hepatitis C Virus in the UK
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Chronic hepatitis C (HCV) is a significant risk factor for cirrhosis and subsequently hepatocellular carcinoma (HCC). HCV patients with cirrhosis are screened for HCC every 6 months. Surveillance for progression to cirrhosis and consequently access to HCC screening is not standardized. Liver biopsy, the usual test to determine cirrhosis, carries a significant risk of morbidity and associated mortality. Transient ultrasound elastography (fibroscan) is a non-invasive test for cirrhosis.
This study assesses the cost effectiveness of annual surveillance for cirrhosis in patients with chronic HCV and the effect of replacing biopsy with fibroscan to diagnose cirrhosis.
A Markov decision analytic model simulated a hypothetical cohort of 10,000 patients with chronic HCV initially without fibrosis over their lifetime. The cirrhosis surveillance strategies assessed were: no surveillance; current practice; fibroscan in current practice with biopsy to confirm cirrhosis; fibroscan completely replacing biopsy in current practice (definitive); annual biopsy; annual fibroscan with biopsy to confirm cirrhosis; annual definitive fibroscan.
Our results demonstrate that annual definitive fibroscan is the optimal strategy to diagnose cirrhosis. In our study, it diagnosed 20 % more cirrhosis cases than the current strategy, with 549 extra patients per 10,000 accessing screening over a lifetime and, consequently, 76 additional HCC cases diagnosed. The lifetime cost is £98.78 extra per patient compared to the current strategy for 1.72 additional unadjusted life years. Annual fibroscan surveillance of 132 patients results in the diagnosis one additional HCC case over a lifetime. The incremental cost-effectiveness ratio for an annual definitive fibroscan is £6,557.06/quality-adjusted life years gained.
Annual definitive fibroscan may be a cost-effective surveillance strategy to identify cirrhosis in patients with chronic HCV, thereby allowing access of these patients to HCC screening.
KeywordsHepatitis C Liver fibrosis Hepatocellular carcinoma Screening Health economics Outcomes research Radiology/imaging
- 1.London: Health Protection Agency. Hepatitis C in the UK 2012. London: Health Protection Agency, Colindale.Google Scholar
- 4.Bedossa P, Poynard T and the French METAVIR Cooperative Study Group. An algorithm for grading activity in chronic hepatitis C. Hepatology. 1996;24:289–293.Google Scholar
- 9.Grishchenko M, Grieve RD, Sweeting MJ, et al and the Trent HCV Study group. Cost-effectiveness of pegylated interferon and ribivarin for patients with chronic hepatitis C treated in routine clinical practice. Int J Technol Assess Health Care. 2009;25:171–180.Google Scholar
- 15.Lok AS, Seeff LB, Morgan TR, et al and the HALT-C Trial Group. Incidence of hepatocellular carcinoma and associated risk factors in hepatitis C-related advanced liver disease. Gastroenterology. 2009;136:138–148.Google Scholar
- 18.Ryder SC. Guidelines for the diagnosis and treatment of hepatocellular carcinoma (HCC) in adults. Gut. 2003;52:iii1–iii8.Google Scholar
- 25.Echosens. Registered technology of EchoSens. EchoSens, Paris. Available at: www.echosens.com.
- 35.Poordad F, McCone J, Bacon BR, et al for the SPRINT-2 investigators. Boceprevir for untreated chronic HCV Genotype 1 infection. N Engl J Med. 2011;364:1195–1206.Google Scholar
- 36.Bacon BR, Gordon SC, Lawitz E, et al for the HCV RESPOND-2 Investigators. Boceprevir for previously treated chronic HCV Genotype 1 infection. N Engl J Med. 2011;364:1207–1217.Google Scholar
- 39.Thompson Coon J, Rogers G, Hewson P, et al. Surveillance of cirrhosis for hepatocellular carcinoma: systematic review and economic analysis. Health Technol Assess. 2007;11:1–206.Google Scholar
- 40.Stamuli E, Kruger J, Hutton J. Cost-effectiveness of ultrasound elastography in the assessment of liver fibrosis. Economic report for the NHS Centre for Evidence-based Purchasing. 2009;CEP08053.Google Scholar
- 41.Hartwell D, Jones J, Baxter L, Shepherd J. Peginterferon alfa and ribavirin for chronic hepatitis C in patients eligible for shortened treatment, re-treatment or in HCV/HIV co-infection: a systematic review and economic evaluation. Health Technol Assess. 2011;15.Google Scholar
- 42.Department of Health. 2010-11 Reference costs publication. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131140. Accessed July 2012.
- 43.Treasury HM. The Green Book. Appraisal and Evaluation in Central Government. Treasury Guidance. London: TSO; 2003 (amended 2011).Google Scholar
- 46.Shepherd J, Jones J, Hartwell D, Davidson P, Price A, Waugh N. Interferon alfa (pegylated and non-pegylated) and ribavirin for the treatment of mild chronic hepatitis C: a systematic review and economic evaluation. Health Technol Assess. 2007;11:11.Google Scholar
- 50.Abu Dayyeh BK, Yang M, Fuchs BC, et al for the HALT-C Trial Group. A functional polymorphism in the Epydermal growth factor gene is associated with risk of hepatocellular carcinoma. Gastroenterology. 2011;141:141–149.Google Scholar
- 53.Han C, Michalopoulos GK, Wu T. Prostaglandin E2 receptor EP1 transactivates EGFR/MET receptor tyrosine kinases and enhances invasiveness in human hepatocellular carcinoma cells. J Cancer Physiol. 2006;207:261–270.Google Scholar
- 55.Adam R, Cailliez V, Majno P, et al. Normalised intrinsic mortality risk in liver transplantation: European liver transplant registry study. Lancet. 2000;356:621–627.Google Scholar
- 56.Canadian Agency for Drugs and Technologies in Health. Transient elastography (FibroScan) for non-invasive assessment of liver fibrosis. 2012Google Scholar
- 57.Fleming KM, Aithal GP, Card TR, West J. All-cause mortality in people with cirrhosis compared with the general population: a population-based cohort study. Liver Int. 2012;32:79–84.Google Scholar
- 58.Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg. 1999;230:309–318.Google Scholar
- 59.Greten TF, Papendorf F, Bleck JS, et al. Survival rate in patients with hepatocellular carcinoma: a retrospective analysis of 389 patients. Br J Cancer. 2005;92:1862–1868.Google Scholar
- 60.Livraghi T, Giorgio A, Marin G, et al. Hepatocellular carcinoma and cirrhosis in 746 patients: long-term results of percutaneous ethanol injection. Radiology. 1995;197:101–108.Google Scholar
- 61.Mondazzi L, Bottelli R, Brambilla G, et al. Transarterial oily chemoembolization for the treatment of hepatocellular carcinoma: a multivariate analysis of prognostic factors. Hepatology. 1994;19:1115–1123.Google Scholar
- 62.Naugler WE, Sonnenberg A. Survival and cost-effectiveness analysis of competing strategies in the management of small hepatocellular carcinoma. Liver Transpl. 2010;16:1186–1194.Google Scholar
- 63.Salomon JA, Weinstein MC, Hammitt JK, Goldie SJ. Empirically calibrated model of hepatitis C virus infection in the United States. Am J Epidemiol. 2002:156:761–773.Google Scholar
- 64.Trevisani F, Santi V, Gramenzi A, et al for Italian Liver Cancer Group. Surveillance for early diagnosis of hepatocellular carcinoma: is it effective in intermediate/advanced cirrhosis? Am J Gastroenterology. 2007;102:2448–2457.Google Scholar
- 65.Connock M, Round J, Bayliss S, Tubeuf S, Greenheld W, Moore D. Sorafenib for the treatment of advanced hepatocellular carcinoma. Health Technol Assess. 2010;14:17–21.Google Scholar
- 66.The Global Burden of Hepatitis C Working Group. Global burden of disease (GBD) for hepatitis C. J Clin Pharmacol. 2004;44:20–29.Google Scholar
- 67.Chen MS, Li JQ, Zheng Y, et al. A prospective randomized trial comparing percutaneous local ablative therapy and partial hepatectomy for small hepatocellular carcinoma. Ann Surg. 2006;243:321–328.Google Scholar
- 68.Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med. 1996;334:693–700.Google Scholar
- 69.Llovet JM, Mas X, Aponte JJ, et al. Cost effectiveness of adjuvant therapy for hepatocellular carcinoma during the waiting list for liver transplantation. Gut. 2002;50:123–128.Google Scholar
- 70.Bismuth H, Majno PE, Adam R. Liver transplantation for hepatocellular carcinoma. Semin Liver Dis. 1999;19:311–322.Google Scholar
- 71.Ladabaum U, Cheng SL, Yao FY, Roberts JP. Cost effectiveness of screening for recurrent hepatocellular carcinoma after liver transplantation. Clin Transplant. 2011;25:283–291.Google Scholar
- 72.Carr B, Carroll S, Muszbek N, Gondek K. Economic evaluation of Sorafenib in unresectable hepatocellular carcinoma. J Gastroenterol Hepatol. 2010;25:1739–1746.Google Scholar