Role of Surveillance in Prevention of Hepatocellular Carcinoma

Abstract

Hepatocellular carcinoma is a common malignancy and one of the important public health problems in India. The surveillance of hepatocellular carcinoma (HCC) is an established approach to detect early cancers in patients with defined risks. However, there are still controversies and issues to be addressed regarding the optimal surveillance methods and interval. The current level of awareness among physicians in India about surveillance is low and the need and most cost effective surveillance strategy in developing country like ours is unclear. This article has tried to discuss these issues in their appropriate perspective. To address this complicated issue, a multicenter randomized prospective study however may be required. ( J CLIN EXP HEPATOL 2014;4:S43-S49) H epatocellular carcinoma (HCC) is the fifth commonest cancer worldwide and third commonest cause of cancer related mortality. 1 In India, the mean incidence of HCC as per four population-based registries was 2.77% for males and 1.38% for females. The prevalence of HCC in India varies from 0.2% to 1.6%. 2,3 It is interesting to note that the consolidated data from cancer registries of India do not reflect HCC as an important malignancy. 4 Risk of HCC development is high in patients with liver cirrhosis of any etiology, particularly with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. 5 Since India has a high prevalence of HBV infection (4% of population, i.e about 40 million Indians) 6 as well as HCV infection (0.3-1.5%) it could contribute to the high incidence of HCC. 7 Other risk factors for HCC like high prevalence of Nonalcoholic Fatty Liver Disease (NAFLD) obesity, diabetes, alcohol consumption among males are also present in India.Nonalcoholic Fatty Liver Disease (NAFLD) particularly its more aggressive form, nonalcoholic steatohepatitis (NASH) is an important factor which can lead to cirrhosis and HCC. It is estimated that nearly two-thirds of obese people have some form of fatty liver, ranging from steatosis to NASH. NASH can progress to liver cirrhosis in 3%-15% and subsequently to liver cancer. 8 A study by Prasad et al showed that age-standardized prevalence rates of metabolic syndrome were 33.5% overall, 24.9% in males and 42.3% in females in India. Authors concluded that metabolic syndrome is a significant public health problem even in one of the poorest states of India. 9 Hence NASH is particularly important in countries like India where metabolic syndrome is on the rise.It is important to note that in the absence of an effective screening program and only 7% of population being covered by cancer registries, under reporting cannot be ruled out. 10 A recent study in which 130 trained physicians independently assigned causes to 122429 deaths, which occurred in 1$1 million homes in 6671 small areas that were randomly selected to be representative of all of India, based on a structured nonmedical surveyor's field report has put the liver cancer as the 4th commonest cause of death in male and 8th commonest cause of death i...

2019 Update of Indian National Association for Study of the Liver Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri II Recommendations

“…80 Level of awareness of physicians managing patients of chronic liver disease is a major factor in surveillance of HCC; there is a need for greater healthcare provider awareness to improve HCC surveillance. 81 Following patients should be subjected to surveillance for HCC: Child's A and B cirrhotic patients of any etiology; Child's C cirrhotic patients of any etiology who are listed for liver transplantation (LT); patients with chronic hepatitis B who have increased risk for HCC according to risk scores such as CU-HCC or PAGE-B; and chronic HCV with advanced fibrosis.…”

Non-alcoholic fatty liver disease associated with hepatocellular carcinoma: An increasing concern

“…Since there is an alarming prevalence of lifestyle disease such as obesity or diabetes, a cost-effective approach would be desired. No definite guidelines have been proposed and large multicentric studies have been recommended to reach consensus979899.…”

Hepatocellular Carcinoma. Part 2: Clinical Presentation and Diagnosis

“…AFP, US, CT, and MRI are examples of methods in which surveillance can be carried out. 19,[27][28][29][30] According to the international guidelines of the American Association for the Study of Liver Disease (AASLD), screening of patients with cirrhosis and patients at high risk of HCC is mandatory, and US should be used every 6 months. AFP, which is the most widely used biomarker, has not been proven to be adequate for surveillance even when combined with US.…”

“…There is much debate regarding the cost-effectiveness of HCC surveillance; 32 however, US every 6 months in cirrhotic patients is the recommended and most cost-effective method for surveillance. 21,27…”