Impact on follow‐up strategies in patients with primary sclerosing cholangitis

Abstract

Background & Aims: Evidence for the benefit of scheduled imaging for early detection of hepatobiliary malignancies in primary sclerosing cholangitis (PSC) is limited.We aimed to compare different follow-up strategies in PSC with the hypothesis that regular imaging improves survival. Methods:We collected retrospective data from 2975 PSC patients from 27 centres. Patients were followed from the start of scheduled imaging or in case of clinical follow-up from 1 January 2000, until death or last clinical follow-up alive. The primary endpoint was all-cause mortality.Results: A broad variety of different follow-up strategies were reported. All except one centre used regular imaging, ultrasound (US) and/or magnetic resonance imaging (MRI).Two centres used scheduled endoscopic retrograde cholangiopancreatography (ERCP) in addition to imaging for surveillance purposes. The overall HR (CI95%) for death, adjusted for sex, age and start year of follow-up, was 0.61 (0.47-0.80) for scheduled imaging with and without ERCP; 0.64 (0.48-0.86) for US/MRI and 0.53 (0.37-0.75) for follow-up strategies including scheduled ERCP. The lower risk of death remained for scheduled imaging with and without ERCP after adjustment for cholangiocarcinoma (CCA) or high-grade dysplasia as a time-dependent covariate, HR 0.57 (0.44-0.75). Hepatobiliary malignancy was diagnosed in 175 (5.9%) of the patients at 7.9 years of follow-up. Asymptomatic patients (25%) with CCA had better survival if scheduled imaging had been performed.

Current epidemiology of cholangiocarcinoma in Western countries

“…However, there is a paucity of studies demonstrating the effectiveness of biomarker-and imaging-based surveillance in reducing CCA mortality. However, three retrospective studies provide evidence for the potential survival benefit of CCA imaging surveillance in PSC [44][45][46]. A study of 830 PSC patients from Mayo Clinic Rochester found patients with imaging surveillance had significantly increased overall survival in patients with CCA (hazard ratio 0.22, 95% confidence interval 0.12-0.41; p<0.001) [45].…”

“…Similarly, yearly imaging was associated with twofold reduction in hepatopancreatobiliary cancers in patients with PSC with concurrent inflammatory bowel disease [46]. Bergquist et al assessed the effects of imaging surveillance strategies from twenty-seven centres from twelve western countries [44]. The authors found scheduled imaging surveillance was associated with a lower risk of overall mortality (hazard ratio 0.61 (0.47-0.80) and improved survival after CCA diagnosis compared to patients without scheduled imaging.…”

“…This lack of consensus guidance means there is a wide variation in surveillance strategies in clinical practice. A retrospective study including 2,975 PSC patients from 10 European countries, USA and Canada showed there was a wide variation of surveillance strategies adopted within centres both within the same and across different countries [44]. There was further variation in the choice of surveillance, with ultrasound, MRI, CA 19-9 and endoscopic retrograde cholangiopancreatography (ERCP) all being employed based on local centre protocols.…”

Autoimmune Lebererkrankungen – ein Update (Teil 2)

“…Erste Studien zeigen, dass regelmäßige Vorsorgeuntersuchungen dazu beitragen können, hepatobiliäre Malignome in früheren Stadien zu entdecken 42 , 43 . Dies wurde jedoch in einer kürzlich vorgestellten, prospektiven Studie aus Schweden – bei allerdings sehr geringer Inzidenz hepatobiliärer Tumoren – nicht bestätigt 44 , 45 .…”

Patient‐reported quality of care in primary sclerosing cholangitis

“…Management and follow‐up strategies for PSC vary considerably between centres and countries, 9,10 likely due to the lack of evidence‐based practice in PSC. Furthermore, they vary according to the age of the patients due to differences in disease course.…”