Cost-Effectiveness Analysis of Interventional Liver-Directed Therapies for a Single, Small Hepatocellular Carcinoma in Liver Transplant Candidates.

PURPOSE: To assess the cost-effectiveness of the three main LRTs (transarterial chemoembolization (TACE), radioembolization (TARE), and percutaneous ablation) as bridging therapy.

METHODS: A cost-effectiveness analysis was performed comparing three LRTs for patients with single ≤ 3 cm HCC over a 5-year time horizon from a payer's perspective. The clinical course, including the transplantation, decompensation resulting in delisting, and need for a second LRT, were based on data from the United Network for Organ Sharing (2016-2019). Costs and effectiveness were measured in US dollars and quality-adjusted life years (QALYs). Probabilistic and deterministic sensitivity analyses were performed.

RESULTS: In patients with a single, small (≤ 3 cm) HCC, a total of 2,594, 1,576, and 903 patients, underwent TACE, ablation, and TARE. Ablation was the dominant strategy with the lowest expected cost and highest effectiveness. Probabilistic sensitivity analysis demonstrated that ablation was the most cost-effective strategy in 93.89% of the simulations. Subgroup analysis was performed for different wait times with ablation remaining the most cost-effective strategy. Sensitivity analysis showed ablation was most effective if the risk of waitlist dropout was <2.00% and the rate of transplantation >15.1% quarterly. TARE was most effective if the dropout risk was <1.19% and the rate of transplantation was >24.0%. TACE was most effective if the dropout risk was <1.01% and rate of transplantation >45.7%. Ablation remained the most cost-effective modality until its procedural cost was >$34,843.

CONCLUSION: Ablation is the most cost-effective bridging strategy for patients with single, small (≤ 3 cm) HCC prior to liver transplant. The conclusion remained robust in multiple sensitivity analyses.