Elsevier

Journal of Hepatology

Volume 59, Issue 2, August 2013, Pages 300-307
Journal of Hepatology

Research Article
Cost-effectiveness of hepatic resection versus percutaneous radiofrequency ablation for early hepatocellular carcinoma

https://doi.org/10.1016/j.jhep.2013.04.009Get rights and content

Background & Aims

Both hepatic resection and radiofrequency ablation (RFA) are considered curative treatments for hepatocellular carcinoma (HCC), but their economic impact still remains not determined. Aim of the present study was to analyze the cost-effectiveness (CE) of these two strategies in early stage HCC (Milan criteria).

Methods

As first step, a meta-analysis of the pertinent literature of the last decade was performed. Seventeen studies fulfilled the inclusion criteria: 3996 patients underwent resection and 4424 underwent RFA for early HCC. Data obtained from the meta-analysis were used to construct a Markov model. Costs were assessed from the health care provider perspective. A Monte Carlo probabilistic sensitivity analysis was used to estimate outcomes with distribution samples of 1000 patients for each treatment arm.

Results

In a 10-year perspective, for very early HCC (single nodule <2 cm) in Child–Pugh class A patients, RFA provided similar life-expectancy and quality-adjusted life-expectancy at a lower cost than resection and was the most cost-effective therapeutic strategy. For single HCCs of 3–5 cm, resection provided better life-expectancy and was more cost-effective than RFA, at a willingness-to-pay above € 4200 per quality-adjusted life-year. In the presence of two or three nodules ⩽3 cm, life-expectancy and quality-adjusted life-expectancy were very similar between the two treatments, but cost-effectiveness was again in favour of RFA.

Conclusions

For very early HCC and in the presence of two or three nodules ⩽3 cm, RFA is more cost-effective than resection; for single larger early stage HCCs, surgical resection remains the best strategy to adopt as a result of better survival rates at an acceptable increase in cost.

Introduction

Diagnosis of hepatocellular carcinoma (HCC) at an early stage (single nodule ⩽5 cm or 2–3 nodules ⩽3 cm), enables the application of potentially curative treatments [1]. Liver transplantation, can be offered rarely; hence, most patients are currently considered for hepatic resection (HR) or ablation as first-line therapies. New randomised controlled trials (RCT), large enough to arrive at a conclusion as to the equivalence or superiority of either of the two modalities, in terms of survival, are eagerly awaited [2], [3], [4]. However, such large trials with a real randomisation seem difficult to be carried out, due to the difficulty in selecting patients equally eligible for both techniques [5]. In the absence of grade A recommendations, current international guidelines suggest surgical resection for early single HCC (⩽5 cm) and cirrhosis without signs of portal hypertension, whereas they propose ablation for early multifocal HCC (two or three nodules ⩽3 cm) and for single small HCCs not having a perfectly preserved liver function [6], [7]. Recent expert opinion raised a point in favour of ablation rather than surgery in very early HCC (single <2 cm), since an extremely high rate of patients can apparently achieve a complete sustained response when undergoing radiofrequency ablation (RFA) [8], [9]. On the other hand, other experts favour the use of resection in early HCC even in the presence of portal hypertension [10]. These uncertainties point out how the recommended first choice treatment strategy for early stage HCC is still a matter of debate without any forecast of a definitive solution [5].

Together with uncertainties regarding the effectiveness of these two competing strategies, there is a significant difference in costs. Nowadays, the clinical utility of any therapeutic strategy should consider not only the magnitude of the survival benefit but also its related cost, i.e., its cost-effectiveness (CE). However, a formal analysis of cost-effectiveness capable of assisting physicians, scientific societies and, ultimately, healthcare managers in the decision-making processes has not yet been elucidated for these two competing treatments. The aim of the present study was therefore to construct a model to estimate CE of resection vs. ablation for early HCC (Milan criteria) in Child–Pugh class A patients and in different tumour size categories, based on a systematic review of the literature and a detailed meta-analysis of the results.

Section snippets

Materials and methods

At first, a meta-analysis of the pertinent literature extracted between January 1, 2000 and April 1, 2012 was performed following the PRISMA and MOOSE guidelines (Fig. 1) [11], [12]. Details about literature search strategy can be found in the Supplementary Materials and methods. Then, results obtained from meta-analysis were utilized to construct a Markov simulation model using TreeAge-Pro-2008 (TreeAge Software Inc., Williamstown, MA, USA), which followed a hypothetical cohort of adult

Meta-analysis results

Seventeen articles, among the many identified by the initial search, fell within the scope of the study [3], [4], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40]. There were two RCT which fulfilled the inclusion criteria [3], [4] whereas all the other studies identified followed an observational design [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40]. Details of each study included in the meta-analysis can be found

Discussion

The choice between radiofrequency ablation and surgical resection in early HCC in cirrhotic patients is still a matter of debate. Surgery is a more radical therapy, but it can more negatively impact the already compromised function of a cirrhotic liver and is subject to postoperative complications; radiofrequency ablation is safer but its ability to obtain complete and sustained tumour necrosis is less predictable. Despite the ongoing debate, current Western international guidelines recommend

Conflict of interest

Nothing to declare for all authors in connection with the treatment modalities included in the current article. F.P. and L.B. received advisory and speaker fees from Bayer and Bracco.

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