A recent modeling-based study compared the cost and outcomes of transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) for the downstaging of hepatocellular carcinoma (HCC) in patients who exceeded the Milan criteria but were within the United Network for Organ Sharing (UNOS) criteria for liver transplant. Investigators in the “Cost-Effectiveness Analysis of Interventional Liver-Directed Therapies for Downstaging of Hepatocellular Carcinoma Before Liver Transplant” study found that TARE is the more cost-effective of the two strategies. The Featured Abstract will be presented Wednesday, March 8, at 3 p.m., Room 222C the Phoenix Convention Center.
“For patients with HCC, especially those that are relatively early stage, getting a liver transplant is the first-line curative treatment and offers the longest survival benefit,” said presenter Xiao Wu, MD, a resident physician at the University of California, San Francisco. “But a significant percentage of patients at diagnosis are beyond the Milan criteria and thus not initially eligible for a liver transplant.”
To meet the threshold required by the Milan criteria (one lesion greater than or equal to 2 cm and less than or equal to 5 cm, or up to three lesions greater than or equal to 1 cm and less than or equal to 3 cm) physicians often turn to downsizing strategies. Though the most commonly used therapies for downstaging are TACE and TARE, Dr. Wu says, there is limited literature comparing the two.
“We’re hoping that the study can provide guidance on the optimal transarterial downstaging therapy for this group of patients,” said Dr. Wu.
The effectiveness of the procedures, measured in quality-adjusted life years (QALYs), was found to be 2.49 QALY for TARE and 2.31 for TACE—a difference equivalent to nearly 3 months in compensated cirrhosis state. Though TARE was more costly ($172,965) compared to TACE ($157,687), the incremental cost-effectiveness ratio of $85,517 per QALY made TARE the more cost-effective strategy.
The researchers also found that, compared to TACE, patients receiving TARE not only required fewer treatments to achieve downstaging, but also had a lower risk of tumor progression.
Opting for a modeling-based study rather than a randomized controlled trial, the researchers compared the subgroup analysis based on tumor characteristics such as alpha fetoprotein cancer rage and number of lesions.
“In this patient population, it would be really hard to do a randomized controlled trial to compare these two strategies because the patient population is so heterogeneous and the practice and management are also very different based on region,” said Dr. Wu. “So we did a modeling study to compare the two strategies, both based on cost and outcomes.”
According to Dr. Wu, the study was inspired by the recent push for downstaging and broadening the criteria for liver transplants.
“More and more experts and guidelines are advocating for patients within the UNOS criteria to receive downstaging therapies for the tumor to be within the Milan criteria, and basically broaden the criteria for liver transplant,” said Dr. Wu. “Multiple studies have shown that for patients who undergo transplant within the Milan criteria and who were downstaged, their outcomes are not that different.”
Looking forward, the researchers are interested in comparing curative therapies for smaller HCCs, such as TARE, radiation segmentectomy and a combination of TACE and ablation, as well as ablation alone.
“We’re interested in looking at those three strategies to see their performance in terms of a cost-effective analysis,” said Dr. Wu. “We’d also like to see if patients with more advanced-stage HCC are aided by adding transarterial radioembolization on top of systemic therapy.”
Dr. Wu acknowledged the interventional radiology and transplant hepatology departments at USCF for their help in this research.
