Hepatology International

, Volume 2, Issue 2, pp 231–236 | Cite as

Economic evaluation of a surveillance program of hepatocellular carcinoma (HCC) in India

  • Shashi Bala Paul
  • Vishnubhatla Sreenivas
  • Manpreet Singh Gulati
  • Kaushal Madan
  • Arun Kumar Gupta
  • Sima Mukhopadhyay
  • Subrat Kumar AcharyaEmail author
Original Article



Surveillance of patients of cirrhosis of liver is practiced for early detection of HCC. No data from any developing country on cost-effectiveness of such a program are available.


Economic evaluation of HCC surveillance was embedded in a prospective study undertaken to estimate the incidence of HCC in 194 cirrhotics. The protocol consisted of 6 monthly abdominal ultrasound (US) and serum alphafetoprotein (AFP) estimation, and yearly triple phase CT. Cost was estimated from the hospital and patient perspectives. Cost-effectiveness ratios for detecting a case of HCC were estimated. Modeling was done to estimate cost effectiveness with different combinations of diagnostic tests.


Cost-effectiveness ratios of HCC surveillance program per HCC case detected were estimated as US$ 280 from the hospital perspective. From patient perspective, these were US$ 9,965 for outstation and US$ 2,808 for local patients. Cost-effectiveness ratio for direct medical cost per case of HCC detected by 6 monthly US and AFP, the EASL protocol, was estimated to be US$ 1,510 in the private sector.


The cost of HCC surveillance program is exorbitant for India (gross national income per capita US$ 620) and possibly other low/middle income countries.


Hepatocellular carcinoma Cost effectiveness Direct medical cost Direct non-medical cost Indirect cost 



The study was partly funded by Indian Council of Medical Research, New Delhi. India.


  1. 1.
    Bolondi L, Sofia S, Siringo S, Gaiani S, Casali A, Zironi G, et al. Surveillance programme of cirrhotic patients for early diagnosis and treatment of hepatocellular carcinoma: a cost-effectiveness analysis. Gut. 2001;48:251–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Mima S, Sekiya C, Kanagawa H, Kohyama H, Gotoh K, Mizuo H, et al. Mass screening for hepatocellular carcinoma: experience in Hokkaido, Japan. J Gastroenterol Hepatol. 1994;9:361–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Yuen MF, Lai CL. Screening for hepatocellular carcinoma: survival benefit and cost-effectiveness. Ann Oncol. 2003;14:1463–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Pisani P, Parkin DM, Ferlay J. Estimates of the world wide mortality from eighteen major cancers in 1985. Implications for prevention and projections of future burden. Int J Cancer. 1993;55:891–3.PubMedCrossRefGoogle Scholar
  5. 5.
    Bruix J, Sherman M, Llovet JM, Beaugrand M, Lencioni R, Burroughs AK, et al. EASL Panel of Experts on HCC. EASL panel of experts on HCC: clinical management of hepatocellular carcinoma. Conclusions of the Barcelona EASL conference. European Association for the study of liver. J Hepatol. 2001;35:421–30.PubMedCrossRefGoogle Scholar
  6. 6.
    Llovet JM, Burroughs A, Bruix J. Hepatocelluar carcinoma. Lancet. 2003;362:1907–17.PubMedCrossRefGoogle Scholar
  7. 7.
    Eisenberg JM. Clinical economics: a guide to the economic analysis of clinical practices. J Am Med Assoc. 1989;262:2879–86.CrossRefGoogle Scholar
  8. 8.
    Drummond MF, Brien O’, Stoddart GL, Torrence GW. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press; 1997.Google Scholar
  9. 9.
    Paul SB, Acharya SK, Sreenivas V, Gulati MS, Madan K, Gupta AK et al. Incidence of hepatocellular carcinoma among Indian patients of cirrhosis of liver. J Gastroenterol Hepatol. 2006;21:A 466.Google Scholar
  10. 10.
    World Bank. The World Development Report. Washington, DC; 2004.Google Scholar
  11. 11.
    UNICEF. State of the world’s children 2006. New York; 2005.Google Scholar
  12. 12.
    Peters DH, Yazbeck AS, Sharma RR, Raman GNV, Pritchett LH, Wagstaff A. Better health systems for India’s poor: findings, analysis and options. Washington, DC: The World Bank; 2002.Google Scholar
  13. 13.
    Yuen MF, Cheng CC, Lauder IJ, Lam SK, Ooi CG, Lai CL. Early detection of hepatocellular carcinoma increases the chance of treatment: Hong Kong experience. Hepatology. 2000;31:330–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Kassirer JP, Mosokowitz AJ, Lau J, Pauker SG. Decision analysis: a progress report. Ann Intern Med. 1987;106:275–91.PubMedGoogle Scholar
  15. 15.
    Beck JR, Pauker SG. The Markov model in medical prognosis. Med Decis Making. 1993;12:419–58.Google Scholar
  16. 16.
    Sarasin FP, Giostra E, Hadengne A. Cost-effectiveness of screening for detection of small hepatocellular carcinoma in western patients with Child-Pugh class A cirrhosis. Am J Med. 1996;101:422–34.PubMedCrossRefGoogle Scholar
  17. 17.
    Saab S, Ly D, Nieto J, Kanwal F, Lu D, Raman S, et al. Hepatocellular carcinoma screening in patients waiting for liver transplantation: a decision analytic model. Liver Transplant. 2003;7:672–81.CrossRefGoogle Scholar
  18. 18.
    Arguedas MR, Chen VK, Elboubeidi MA, Fallon MB. Screening for hepatocellular carcinoma in patients with hepatitis C cirrhosis: a cost utility analysis. Am J Gastroenterol. 2003;98:679–90.PubMedCrossRefGoogle Scholar

Copyright information

© Asian Pacific Association for the Study of the Liver 2008

Authors and Affiliations

  • Shashi Bala Paul
    • 1
  • Vishnubhatla Sreenivas
    • 2
  • Manpreet Singh Gulati
    • 1
  • Kaushal Madan
    • 3
  • Arun Kumar Gupta
    • 1
  • Sima Mukhopadhyay
    • 1
  • Subrat Kumar Acharya
    • 3
    Email author
  1. 1.Department of Radio-diagnosisAll India Institute of Medical SciencesNew DelhiIndia
  2. 2.Department of BiostatisticsAll India Institute of Medical SciencesNew DelhiIndia
  3. 3.Department of GastroenterologyAll India Institute of Medical SciencesNew DelhiIndia

Personalised recommendations