Effectiveness of surveillance for hepatocellular carcinoma in clinical practice: A United States cohort

Abstract

Background & Aims The effectiveness of surveillance for hepatocellular carcinoma (HCC) in reducing cancer related mortality among patients with cirrhosis is largely unknown. The objective of this study was to study the effectiveness of HCC surveillance in the national Veterans Administration (VA) clinical practice. Methods We conducted a retrospective cohort study of patients with HCC during 2005–2010 by reviewing patients’ medical records to determine receipt of HCC surveillance in the 2 years prior to HCC diagnosis. We determined association of HCC surveillance with overall mortality adjusting for age, risk factors, MELD score, co-morbidity index, AFP levels, healthcare utilization, Barcelona Clinic Liver Cancer (BCLC) stage, and treatment. We accounted for lead and length time biases. Results Of 887 patients with HCC, only 412 (46.5%) received any surveillance prior to HCC diagnosis. Patients who received surveillance were significantly more likely to have early stage disease HCC (BCLC stage 0/A 27.2% vs. 11.6%) and receive potentially curative (20.9% vs. 11.6%) or palliative (59.2% vs. 45.5%) treatments compared to those without HCC surveillance. Receipt of HCC surveillance was associated with 38% reduction in mortality risk (unadjusted HR 0.62, 95% CI 0.54–0.71) that declined to 20% (HR 0.80, 95% CI 0.69–0.94) after adjusting for HCC stage and treatment, compared to those without HCC surveillance. Conclusions Among patients with HCC, pre diagnosis HCC surveillance is associated with a significant 38% reduction in overall mortality. The reduction in mortality risk with surveillance is mediated via stage migration and receipt of HCC specific treatment.

Hepatocellular carcinoma is diagnosed at a later stage in alcoholic patients: Results of a prospective, nationwide study

“…10,11 Various assumptions can be made to explain why patients with alcohol-related HCC have reduced survival in comparison with patients with non-alcohol-related HCC: a diagnosis at a later stage due to lower rates of HCC screening, worse liver function and/or ongoing alcohol consumption preventing curative options, and discrimination against alcoholic patients leading to less aggressive treatment options. 18,[22][23][24][25] However, in our study, the rates of implementation of a cirrhosis follow-up program were comparable in the 2 groups (<30%) and could not per se explain the difference in survival between them. 21 Lack of a diagnosis of cirrhosis prevents the implementation of screening programs, which are associated with a diagnosis at an earlier stage, curative treatment, and improved survival.…”

Improved Performance of Serum Alpha-Fetoprotein for Hepatocellular Carcinoma Diagnosis in HCV Cirrhosis with Normal Alanine Transaminase

“…(1) The overall survival of patients with HCC has been improving over the past 3 decades, in part due to earlier detection of cancers that are amenable to potentially curative treatments. (2,3) As early diagnosis is a key determinant of clinical outcomes in patients with HCC, the major liver societies recommend semiannual HCC surveillance in high risk patients including patients with cirrhotic liver disease. (4–6)…”

Tailored Algorithms for Hepatocellular Carcinoma Surveillance: Is One-Size-Fits-All Strategy Outdated?

“…Given an identifiable at-risk population, such as those with chronic viral hepatitis and/or cirrhosis, HCC surveillance using biannual ultrasound has been shown, in cohort studies and their meta-analyses, to be associated with improved survival, improved tumor detection at earlier stage, and improved curative treatment rates [4, 5]. These findings support the recommendation for biannual HCC surveillance with ultrasound with or without serum alpha-fetoprotein (AFP) in subjects at sufficient risk for HCC [6–8].…”