1Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, 8 College Road, Singapore, 169857; Office of Clinical Sciences, Duke-NUS Graduate Medical School, 8 College Road, Singapore, 169857.
Objective: Both liver resection (LR) and cadaveric liver transplantation (CLT) are potentially curative treatments for patients with hepatocellular carcinoma (HCC) within the Milan criteria, and adequate liver function. Adopting either as first-line therapy carries major cost and resource implications. The objective of this study was to estimate the relative cost-effectiveness of LR against CLT for patients with HCC within the Milan criteria using a decision analytic model. Design: A Markov cohort model was developed to simulate a cohort of patients aged 55 years with HCC within the Milan criteria and Child-Pugh A/B cirrhosis, undergoing LR or CLT, and followed-up over their remaining life expectancy. Analysis was performed in different geographical cost settings - USA, Switzerland and Singapore. Data sources: Transition probabilities were obtained from systematic literature reviews, supplemented by databases from Singapore and the Organ Procurement and Transplantation Network (USA), respectively. Utility and cost data were obtained from open sources. Results: LR produced 3.9 quality-adjusted life years (QALYs) while CLT had an additional 1.4 QALYs. Incremental cost-effectiveness ratio (ICER) of CLT versus LR ranged from $111,821/QALY in Singapore to $156,300/QALY in Switzerland, and was above thresholds for cost-effectiveness in all three countries. Sensitivity analysis revealed that CLT-related 5-year cumulative survival, one-time cost of CLT, and post-LR 5-year cumulative recurrence rate were the most sensitive parameters in all cost scenarios. ICERs would reduce below threshold when CLT-related 5-year cumulative survival exceeded 84.9 and 87.6% in Singapore and USA respectively. For Switzerland, ICER remained above cost-effectiveness threshold regardless of the variations. Conclusion: In patients with HCC within Milan criteria and Child-Pugh A/B cirrhosis, LR is more cost-effective than CLT, across 3 different costing scenarios - USA, Switzerland, Singapore.