A Health Economic Evaluation of Routine Hepatocellular Carcinoma Surveillance for People with Compensated Cirrhosis to Support Australian Clinical Guidelines

Joachim Worthington; Emily He; Michael Caruana; Stephen Wade; Barbara de Graaff; Anh Le Tuan Nguyen; Jacob George; Karen Canfell; Eleonora Feletto

doi:10.1177/23814683251344962

A Health Economic Evaluation of Routine Hepatocellular Carcinoma Surveillance for People with Compensated Cirrhosis to Support Australian Clinical Guidelines

MDM Policy Pract. 2025 Jun 26;10(1):23814683251344962. doi: 10.1177/23814683251344962. eCollection 2025 Jan-Jun.

Authors

Joachim Worthington¹, Emily He¹, Michael Caruana², Stephen Wade¹, Barbara de Graaff³, Anh Le Tuan Nguyen^{3

4}, Jacob George⁵, Karen Canfell², Eleonora Feletto¹

Affiliations

¹ The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia.
² School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
³ Menzies Institute for Medical Research, The University of Tasmania, Hobart, Tasmania.
⁴ WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and Immunity.
⁵ Storr Liver Centre, The Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney, NSW, Australia.

Abstract

Background. Liver cancer is the only cancer in Australia with rising incidence and mortality rates, despite the potential for early detection through surveillance of high-risk individuals. Hepatocellular carcinoma (HCC), the most common form of primary liver cancer, has curative treatment options available if detected early. Six-monthly HCC surveillance is recommended for people with liver cirrhosis and was proposed for inclusion in the 2023 Cancer Council Australia Clinical Practice Guidelines for Hepatocellular Carcinoma Surveillance for People at High Risk in Australia. To evaluate the proposed 2023 guideline recommendation, we developed Policy1-Liver, a novel mathematical model of liver disease, HCC, and surveillance. We then assessed the health and economic implications of 6-monthly HCC surveillance in Australia via ultrasound, with or without alpha-fetoprotein. Methods. Policy1-Liver was calibrated to existing data sources on liver disease, HCC, and health care costs in Australia. We assessed the impact of 6-monthly routine HCC surveillance with ultrasound with or without alpha-fetoprotein testing as well as a range of other sensitivity analyses and alternative scenarios such as varying surveillance adherence and intervals to assess potential future modifications to surveillance. Results. We estimated that 6-monthly HCC surveillance, with or without alpha-fetoprotein, can increase early-stage diagnoses to up to 81% and reduce HCC mortality by 22% in people with cirrhosis. We estimate an incremental cost-effectiveness ratio of $28,423 per quality-adjusted life-year for 6-monthly surveillance with ultrasound alone compared with no surveillance. Conclusions. These findings support guideline-recommended 6-monthly HCC surveillance with ultrasound, affirming its health benefits and cost-effectiveness, and demonstrate the potential to improve cost-effectiveness by refining surveillance intervals and improving early-stage HCC survival. Supporting implementation of the surveillance guidelines will play a key role in improving HCC mortality rates in Australia.

Highlights: Routine surveillance can improve the likelihood of early-stage detection of liver cancer, improving survival.Our modeling found that routine HCC surveillance with ultrasound would be cost-effective for people with liver cirrhosis in Australia.These findings can inform guidelines and investment in liver cancer control for high-risk patients.

Keywords: cancer screening; health economics; hepatocellular cancer; liver cancer; mathematical model; public health; secondary prevention.