Healthcare costs associated with hepatocellular carcinoma and the value of care

Hepatocellular carcinoma (HCC) is the fifth most prevalent cancer worldwide and the third most frequent cause of cancer-related mortality.1, 2 More than 700,000 cases were diagnosed in 2008. At least 80% of cases are diagnosed in areas with poor healthcare infrastructures, leaving the vast majority of patients without proper treatment. In Western countries the incidence and prevalence of HCC are also increasing. In the U.S. the age-adjusted incidence is around 4.2 per 100,000, accounting for about 20,000 new cases diagnosed each year.1, 2 Several treatment options are available to patients with early to intermediate stage HCC with similar short-term results. Liver transplantation is curative for both HCC and the accompanying liver cirrhosis; however, it can be offered only to a minority of patients. HCC imposes a severe human and economic burden on patients, their families, and society. The assessment of the burden of disease is an area of growing interest and is used to establish public health objectives, to inform decisions on the allocation of healthcare resources across disease categories, and to evaluate the costs and benefits of health interventions in specific fields.3, 5 Core measures of disease burden include incidence, prevalence, mortality, and the cost of illness (COI). The COI includes direct costs, morbidity costs (i.e., the lost income due to work disability and absenteeism), and the mortality costs (i.e., the loss of income associated with premature death). A word of caution is needed when analyzing cost data without reference to the outcomes. Cost data are useful for budgetary reasons, but the real goal should be to understand the value of the care for a given condition, and this depends on both costs and outcomes, i.e., on the ability to achieve the best possible outcome using the appropriate amount of resources.9 Both dimensions of the value of care must be taken into account in decision making. Thein et al.'s study makes a strong economic case for HCC prevention. This is very important because the development of HCC is associated with a number of preventable risk factors. Some of them, including alcohol, obesity/overweight, and exposure to hepatitis viruses, could be modified by lifestyle interventions. Vaccination against hepatitis B virus (HBV) has proved to be an effective measure to reduce the incidence of HCC in the countries that have adopted it. Life-long treatment with antivirals to suppress HBV replication reduces the incidence of liver cirrhosis, hepatic decompensation, and liver cancer.10 Successful eradication of hepatitis C virus (HCV) also reduces the incidence of liver decompensation and HCC. Newer and more active drugs able to achieve very high rates of HCV clearance, even in previous nonresponders to peg-interferon and ribavirin are now available, and interferon-free antiviral regimens are around the corner. The successful implementation of these complex preventive and therapeutic interventions requires specialized care and Hepatology services able to recognize and prevent risk factors and to manage chronic liver disease across the continuum of disease stages. It also requires adequate vision and funding from policy-makers. The value of these services is reciprocal to the burden of disease and can be expressed in terms of reduction in the incidence (i.e., cases avoided), reduction in mortality (i.e., live years saved and quality-adjusted life years saved), and reduction in cost of illnesses. Often policy-makers tend to think that prevention is costly, as it needs funding here and now. Articles like Thein et al.'s provide evidence that failure to prevent can be even more costly: here, now, and in the future. Lorenzo G. Mantovani1Mario Strazzabosco2 1Department of Clinical Medicine and Surgery di Medicina Clinica e Chirurgia, University of Napoli Federico II, Napoli, Italy 2Digestive Disease Section, Department of Surgical and Medical Transplational Sciences, University of Milan-Bicocca, Milan, Italy, and Yale University Liver Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT