Treatment of HCC in patients with hepatitis C cirrhosis is costly
The real-world cost of care to treat hepatocellular carcinoma for patients with hepatitis C cirrhosis is very high, according to findings from a retrospective cohort study.
A common complication of chronic hepatitis C virus (HCV) infection, hepatocellular carcinoma (HCC) occurs at a rate of between 3% and 5% annually among patients with concomitant cirrhosis. In the U.S., the incidence of HCC has risen each year, and has tripled in the last two decades.
However, antiviral therapies could reduce the burden of HCV in the U.S., and thus, the incidence of HCC.
Elliott B. Tapper
“Two of the principle drivers of the cost of care for patients with chronic HCV are the complications of decompensated cirrhosis and HCC,” Elliott B. Tapper, MD, a clinical fellow in medicine at Beth Israel Deaconess Medical Center, and colleagues wrote. “HCV therapy, therefore, presented a tradeoff. The upfront costs of viral eradication could be offset by the prevention and cost of complications in the long run. Accordingly, data are needed on the true costs of HCC care to structure realistic cost-effectiveness models.”
Thus, Tapper and colleagues sought to determine the direct costs of care for a cohort of patients with HCV that is complicated by cirrhosis and HCC.
The investigators randomly selected 100 patients (mean age, 59.2 years; men, n = 81) with HCV cirrhosis and HCC who were seen at a U.S. transplant center between January 1, 2003 and May 5, 2013. They categorized patients by their primary treatment modality, Barcelona class and transplant status.
To calculate expenses, researchers considered the costs of procedures, imaging, hospitalization, any prescribed or administered medications, and subsequent care of the patient until the end of follow-up or death.
Overall, the median costs were $176,456 (interquartile range [IQR], $84,489-$292,192) per patient, which equated to $6,279 (IQR, $4,043-$9,720) per patient-month of observation.
The median costs per patient-month were $7,492 (range, $5,137-$11,057) for transplant patients and $4,830 for nontransplant patients.
Patients with Barcelona A4 disease had the highest median monthly cost ($11,349) followed by patients who received chemoemobilization and underwent transplantation ($10,244) and those who received chemoemobilization but did not proceed to transplant ($8,853).
Transarterial chemoemobilization (TACE) was independently associated with a 28% (95% CI, 11-45) increase in costs, whereas radiofrequency ablation was independently associated with a 22% (95% CI, 7-37) decrease in costs. Transplantation significantly increased costs 30% (95% CI, 14-46).
The median OS for the entire cohort was 27 months (IQR, 17-49), whereas it was 43 months (IQR, 28-67) among transplant patients and 20 months (IQR, 11-28) among nontransplant patients.
After transplantation, those who went on to receive stereotactic body radiation had the longest median OS (64 months; IQR, 36-72), whereas those who underwent TACE had the shortest OS (32 months; IQR, 19-38).
Among nontransplant patients, patients who underwent resection had the longest median OS (29 months; IQR, 19-33) and those who received stereotactic body radiation had the shortest (10 months; IQR, 7-19).
“Our work extends the literature on HCC economics in important ways by providing patient-level data and contextualizing the costs by Barcelona class and first treatment modality,” Tapper and colleagues wrote.
There were several study limitations, including the exclusion of cost data on radioemobilization, because this modality was not available at the center during the study period.
Additionally, the cohort was derived from a transplant center in the Northeastern part of the U.S. where there is an association with a longer wait time for liver transplantation and higher model for end-stage liver disease scores. With so many patients going on to receive a transplant, the researchers acknowledged data may not be generalizable to those practices without access to transplantation.
Further, these data represent costs and not charges, which can vary widely.
In an accompanying editorial, Sharon W. Kwan, MD, assistant professor in the department of radiology at University of Washington School of Medicine and attending interventional radiologist for the Seattle Cancer Care Alliance, wrote that neither this study, nor other similar studies have taken into account the greater cost of HCC — lost productivity and the impact on families and caregivers of the patients.
Patients with cancer have more than 2.5-times higher risk for bankruptcy, and their caretakers report high rates of depression and psychological distress, Kwan wrote.
Still, there would be large upfront costs to broadly treat HCV infection.
“This affordability problem is a tremendous one and many payers should be applauded for their thoughtful efforts to maximize access to treatment within current budget constraints,” she wrote. “Nonetheless, as some payers continue to restrict access for certain patients, they must be mindful that ‘kicking the can down the road’ is not an acceptable solution when the proverbial can is a multibillion dollar one accompanied by unquantifiable human suffering and loss.” – by Anthony SanFilippo
Disclosure: Tapper and Kwan report no relevant financial disclosures. Two other researchers report consultant/advisory roles with, research grants from and other financial relationships with AbbVie, Achillion, Bristol-Myers Squibb, Cocrystal, Echosens, Gilead, GlaxoSmithKline, Janssen, Ligand, Merck, Roivant, Sandhill Scientific, Shionogi and Spring Bank.