Cost-effectiveness analysis of interventional liver-directed therapies for downstaging of hepatocellular carcinoma before liver transplant

Purpose: Transarterial chemoembolization (TACE) and radioembolization (TARE) are two most used modalities for patients with hepatocellular carcinoma (HCC) while awaiting liver transplant (LT). The purpose of this study is to perform a cost-effectiveness analysis comparing TACE and TARE for downstaging patients with HCC. Methods: A cost-effectiveness analysis was performed comparing TACE and TARE in downstaging HCC over a 5-year time horizon from a payer’s perspective. The clinical course, including those who achieved successful downstaging leading to LT and those that failed downstaging with possible disease progression, were obtained from the United Network for Organ Sharing. Costs and effectiveness were measured in US dollars and quality-adjusted life years (QALYs). Probabilistic and deterministic sensitivity analyses were performed. Results: TARE achieved a higher effectiveness 2.51 QALY (TACE: 2.29 QALY) at a higher cost $172,162 (TACE: $159,706), with the incremental cost-effectiveness ratio of $55,964 /QALY, making TARE the more cost-effective strategy. The difference in outcome was equivalent to 104 days (nearly 3.5 months) in compensated cirrhosis state. Probabilistic sensitivity analyses showed TARE was more cost-effective in 91.69% of 10,000 Monte Carlo simulations. TARE was more effective if greater than 48.2% of patients who received TACE or TARE were successfully downstaged (base case: 74.6% from pooled analysis of multiple published cohorts). TARE became more cost-effective when the cost of TACE exceeded $4,831 (base case: $12,722) or when the cost of TARE was lower than $43,542 (base case: $30,609). Subgroup analyses identified TARE to be the more cost-effective strategy if the TARE cohort required one fewer LRT than the TACE cohort. Conclusion: TARE is the more cost-effective downstaging strategy for patients with HCC exceeding Milan criteria when compared to TACE.