Assessing efficacy of hepatocellular carcinoma prediction scores to prioritise hepatitis B surveillance in the COVID‐19 era

Abstract

Objective An estimated 250 million people worldwide are chronically infected with hepatitis B virus (HBV), the leading cause of hepatocellular carcinoma (HCC) globally. The novel Sars‐cov2 virus continues to spread at an alarming rate, and with guidance at the onset of the pandemic recommending the deferral of HCC surveillance, the implications on liver cancer care are now emerging and highlight the urgent need for reorganisation of services. Methods We analysed how five HCC risk prediction scores could aid stratification of patients with chronic HBV. We calculated scores using parameters measured from 3 years prior (where available, n = 17) and at the time of HCC diagnosis in all adult patients with chronic HBV diagnosed with HCC (n = 46), and controls (n = 100). We compared the number of patients requiring cancer surveillance according to each score and regional surveillance guidance. Results The aMAP score had the highest discriminatory performance in HCC risk prediction at 3 years (area under receiver‐operating characteristic curve (auROC) of 0.824), followed by the mREACH B score (auROC of 0.719), and mPAGE B score (auROC of 0.742). However, only the mREACH B score had a negative predictive value (NPV) >99%. Applying the mREACH B score to our HBV cohort identified 11 patients requiring HCC surveillance, compared with 62 under current guidelines. Conclusion The use of HCC risk prediction scores could streamline the surveillance of patients with chronic HBV at a time of extremely limited resources. Overall, the mREACH B score had both a strong discriminatory performance and a high NPV, thus safely identifying low risk patients not requiring surveillance.

Risk factors for hepatocellular carcinoma at baseline and 1 year after initiation of nucleos(t)ide analog therapy for chronic hepatitis B

“…It has been posited that fibrosis, hepatic dysfunction, and metabolic disorders are important for long‐term prediction of HCC risk. This Japanese nationwide multicenter cohort study also validated the utility of REAL‐B and aMAP scores for the prediction of HCC development with high accuracy in patients with HBV, as previously reported in other countries 38–41 . These results support the hypothesis that metabolic, genetic, and/or epigenetic factors associated with carcinogenesis may have accumulated in the background liver during HBV infection as the risk of HCC development persists even in patients who have achieved prolonged complete viral suppression 42 .…”

“…The accuracy of AFP previously reported in other countries. [38][39][40][41] These results support the hypothesis that metabolic, genetic, and/or epigenetic factors associated with carcinogenesis may have accumulated in the background liver during HBV infection as the risk of HCC development persists even in patients who have achieved prolonged complete viral suppression. 42 It is also important to understand that current NA therapy does not fully eliminate the risk of developing HCC.…”

Impact of SARS-CoV-2 Pandemic on the Management of Patients with Hepatocellular Carcinoma

“…However, given the heterogeneous growth pattern of HCC, the choice to postpone surveillance should be evaluated on a case-by-case basis [ 48 ]. Some authors suggest stratifying the risk of HCC using scores to identify patients at high risk, for whom surveillance should not be postponed [ 49 , 50 ]. Moreover, due to the elevated risk of COVID-19 exposure associated with the close contact between physician and patient during ultrasound examination, the Asian Pacific Association for the Study of the Liver (APASL) recommends limiting the use of this practice for surveillance, preferring CT (computed tomography) or MRI (magnetic resonance imaging) in patients at high HCC risk [ 51 ].…”

Unique Features of Hepatitis B Virus-Related Hepatocellular Carcinoma in Pathogenesis and Clinical Significance

“…For surveying the HBV patients with the exacerbation probability, the HCC prediction score focusing on the measurement of hepatic fibrosis was recently evaluated in the HBV cohort. It displayed a superior discriminatory performance for identifying CHB patients at high risk of HCC development [ 164 ]. The concept of monitoring the at-risk HBV population by surveillance of the patients with progressive fibrosis via noninvasive approaches but not a liver biopsy is expected for cost-effective prevention of end-stage hepatic diseases.…”