Cost-effectiveness Analysis of Atezolizumab Plus Bevacizumab Versus Lenvatinib in Intermediate-stage Hepatocellular Carcinoma: A Real-world Retrospective Study

Background/Aim: The optimal systemic therapy for intermediate-stage (BCLC-B) hepatocellular carcinoma (HCC) remains undefined. While transarterial chemoembolization (TACE) has long been the standard of care, increasing use of molecular-targeted agents and immune checkpoint inhibitors (ICIs), including atezolizumab plus bevacizumab (Atez/Bev) and lenvatinib (LEN), has shifted therapeutic paradigms. This study compared real-world effectiveness, safety, and cost-effectiveness of Atez/Bev versus LEN for BCLC-B HCC in Japan. Patients and Methods: This single-center, retrospective cohort study analyzed 55 consecutive patients with BCLC-B HCC: 33 received Atez/Bev and 22 received lenvatinib. Clinical outcomes, treatment-related adverse events, total healthcare expenditures (drugs costs, hospitalization, procedures, imaging, laboratory tests, supportive care) were assessed. Life-years gained (LYG) were estimated using mean overall survival, and incremental cost-effectiveness ratios (ICERs) were calculated. Results: Baseline age and body weight were comparable between groups. The Atez/Bev cohort had larger tumors and more impaired liver function. No significant differences were observed in tumor response, median overall survival (OS), or progression-free survival (PFS). Mean total healthcare expenditures per patient were significantly lower with lenvatinib (65, 227. 9) than with Atez/Bev (101, 480. 1; p=0. 036), primarily as a result of reduced drug acquisition costs (Atez/Bev: 70, 000; LEN: 33, 241. 4; p=0. 007). Life-years lost with Atez/Bev versus LEN totaled 0. 46 years (mean OS: Atez/Bev: 17. 82 months; LEN: 23. 27 months). LEN dominated Atez/Bev (ICER=−161, 896. 5 per LYG). Conclusion: Although Atez/Bev and LEN confer similar survival in BCLC-B HCC, lenvatinib offers superior cost-effectiveness in the Japanese healthcare setting. These findings underscore the importance of integrating economic considerations into treatment selection for intermediate-stage HCC.