Aims: Liver cancer death rates have tripled in Australia over the past two decades, and are expected to rise further. Over six million Australians are at risk due to viral hepatitis B or C, metabolic factors (overweight/obesity, diabetes), and/or alcohol use. Routine surveillance can improve early detection, but is not feasible at a population scale without risk-based triaging.
The 2023 hepatocellular carcinoma (HCC) clinical guidelines recommend that people with late-stage liver disease (cirrhosis) receive 6-monthly ultrasound surveillance to detect HCC, the most common form of liver cancer. However, for people with early-stage liver disease (fibrosis), there is limited evidence on cost-effective surveillance.
We estimated the health benefits and cost-effectiveness of routine surveillance for people at risk of liver disease, using low-cost biomarker (FIB-4) to triage patients.
Methods: We developed the Policy1-Liver model of liver disease and cancer, and calculated the health benefits (quality-adjusted life-years/QALYs), costs, and patient burden associated with liver cancer surveillance. We assessed initial triaging with FIB-4 biomarker testing, and ongoing risk-tailored surveillance using FIB-4 biomarker and FibroScan for people at low risk, and liver ultrasound for people with liver cirrhosis.
Results: Without triaging, 6-monthly ultrasound surveillance reduces HCC mortality by 22% and was cost-effective ($28,400 per quality-adjusted life-year) compared to no surveillance in people with cirrhosis, but was not cost-effective for people without liver cirrhosis. Unstratified surveillance using FIB-4 biomarker testing and FibroScan was cost-effective for those with significant fibrosis but not those with limited fibrosis. Fully risk-stratified surveillance, including baseline risk stratification with FIB-4, improved cost-effectiveness significantly to $16,886/QALY (highly cost-effective).
Conclusions: Optimising the target cohorts, technologies, frequencies, and follow-up for liver cancer surveillance is essential to improve efficiency and manage health system burden. Biomarker based triaging should be utilised as part of a population-level surveillance program for Australians at high risk of HCC.