The cost-effectiveness of screening for hepatocellular carcinoma in hepatitis C-related cirrhosis.

Background. Approximately four minion individuals in the United States are infected with hepatitis C virus (HCV). The relative risk of hepatocellular carcinoma (HCC) in patients with hepatitis C-related cirrhosis is at least 7 to 10 times that of the general population. The majority of patients who develop symptoms from HCC harbour tumors that are at an advanced and rapidly fatal stage. Screening has therefore been advocated as a mean of reducing cancer-related deaths. Objective. To determine, from a Canadian perspective, the cost-effectiveness of screening for HCC with biannual liver ultrasound (US) and alpha foetoprotein levels (AFP) in patients with well compensated hepatitis C-related cirrhosis. Methods. Decision analysis with a Markov model was used to simulate a cohort of 3 500 patients with compensated HCV related cirrhosis who would either be screened biannually with US and AFP or be followed expectantly. Therapeutic alternatives included surgical resection and percutaneous ethanol injection (PEI). The probabilities of clinical events were extracted from a systematic review of the literature on HCC and hepatitis C in Western patients; costs were determined from a third party payer perspective, in 1997 Canadian dollars; utilities were generated from a computerized interview of members of the general public; costs and utilities were discounted at 3% per year. Results. Screening is associated with an incremental cost-effectiveness ratio of 6 820 dollars per quality-adjusted life year ($/QALY). Screening was an economically attractive strategy over the entire range of possible values of all variables. Conclusion. Screening for HCC with liver US and AFP in hepatitis C-related cirrhosis is a highly cost-effective strategy, even in populations with a low incidence of HCC