Screening for Hepatocellular Carcinoma in Chronic Liver Disease

Abstract

Management of the Unilateral Shoulder Impingement SyndromeTO THE EDITOR: On the surface, Rhon and colleagues' thoughtful study (1) shows the effectiveness of subacromial corticosteroid injection and manual physical therapy (MPT) to treat the shoulder impingement syndrome (SIS). However, several factors complicate the comparison of MPT with medical intervention and perhaps limit this study's otherwise valuable contribution.First, the manual therapy approach used was welldescribed in Rhon and colleagues' study (1) and elsewhere (2). However, physical therapists in clinical practice typically assess the presence and quality of symptoms in relation to patient movement and position, not according to a pathoanatomical diagnosis, such as SIS. Therefore, including MPT as a treatment for SIS may be misleading. The authors should have emphasized the idea that MPT treats the mechanical stresses that may lead to SIS, whereas corticosteroid injection more directly affects the structures that have been injured.Second, manual physical therapists continually reassess and adjust treatment on the basis of the patient's symptomatic changes structured as a test-retest model (establish a baseline, do an intervention, and then retest to look for change from the baseline). This model has been validated (3) and is the common thread linking many assessment approaches used by all types of physical therapists. This model differs from a physician's typical assessment and treatment in that therapists spend more time (generally 2 to 3 sessions weekly for at least 4 weeks) observing patients move and evaluating their response to various noninvasive interventions.Third, this study may not have sufficiently emphasized the patient education process. Many musculoskeletal conditions involving the shoulders have high recurrence rates (4), particularly when the mechanism of injury is progressive and is thought to result from repetitive overuse of the injured area. In these frequent cases, resolution and recurrence of symptoms may simply be part of the natural history of the condition; short-term pain control and improved functionality would not be the ultimate goal of intervention. Physical therapists educate their patients to become their own "selfassessors" and learn how and when to use appropriate self-treatment techniques as developed through the assessment approach used when deciding on suitable manual techniques.Finally, corticosteroid injection and MPT often work in synergy: The former decreases inflammation, and the latter decreases the mechanical stress that may have caused the symptoms in the first place. Including a third group that received both interventions might have allowed for a more clinically relevant comparison.

Surveillance for hepatocellular cancer

“…19,20 A single Chinese randomised controlled trial did demonstrate a survival benefit in those screened when compared to the control group. 21 However, this study has been criticised due to its design and subsequent analysis, 22 and it is likely to have overestimated the benefits of surveillance due to these concerns.…”

Direct‐acting antiviral drugs and hepatitis C virus: A therapeutic revolution?

“…Although to our knowledge there are few data regarding the true effectiveness of HCC screening, a recent meta-analysis found that HCC surveillance is associated with significantly improved early-stage detection (odds ratio [OR], 2.08; 95% confidence interval [95% CI], 1.80-2.37), curative treatment rates (OR, 2.24; 95% CI, 1.99-2.52), and prolonged survival (OR, 1.90; 95% CI, 1.67-2.17), even in studies adjusted for lead time bias. 5 It is also important to emphasize that a prerequisite for effective screening is the identification of an appropriate population, an area that should be actively investigated as SVR becomes more frequent. As such, further studies need to be performed that identify those individuals achieving SVR who remain at highest risk of developing HCC to select those who would most benefit from screening.…”

“…However, a systematic review of the benefits-to-harm ratio of HCC screening in patients with liver disease confirmed the lack of evidence of a benefit for patients. 5 Long raw data analyses of observational studies have repeatedly shown that nonscreened patients die at an older age than screened patients (lead time and length time bias) and, among the 3 randomized controlled trials that to my knowledge are the only ones currently available, only one, from China, is positive but has several major flaws. [6][7][8] In a large European cohort, the population-attributable fraction for tobacco use in patients with HCC was 47.6%, which is more than twice the population-attributable fraction of the second most attributed risk factor (HCV at 20.9%).…”

Surgical management of hepatocellular carcinoma

“…Both the AASLD and EASL-EORTC guidelines recommend 6 monthly surveillance using abdominal ultrasonography in high risk patients, although the definition of which patients are considered high risk varied [10,11] Interestingly, a systematic review of the benefits and harms of HCC screening in patients with chronic liver disease found only poor quality evidence to support the benefits of screening. Of the two randomised controlled trials reviewed, only one demonstrated a survival benefit (ultrasound screening) and one found no difference in all-cause mortality (alpha-feto protein screening) [12] . Improvements in surgical technique and perioperative care have led to a fall in the morbidity and mortality of liver resection over the last two decades.…”