Ultrasound screening and risk factors for death from hepatocellular carcinoma in a high risk group in Taiwan

Abstract

Although previous studies have demonstrated the ability of ultrasonography (US) screening to detect small asymptomatic hepatocellular carcinoma (HCC), the efficacy of US screening in reducing deaths from HCC still remained unresolved. A 2-stage screening program was designed to identify a high risk group in 7 townships in Taiwan by 6 markers (of risk for HCC) and repeated US screening was further applied to those with at least 1 positive result for the 6 markers, with a range of 3-to 6-month inter-screening intervals to those with liver cirrhosis or other chronic liver diseases and an annual screening regime for the remaining subjects with normal findings according to US. The 4,843 subjects in this cohort were followed up for an average of 7 years. We compared 4,385 attenders with 458 non-attenders, in conjunction with baseline assessment for self-selection bias. In addition, we assessed baseline variables with respect to their effects on risk of incidence of and mortality from HCC and on risk of incidence of liver cirrhosis. The difference in mortality between attenders and non-attenders was then re-estimated adjusting for significant predictors of cirrhosis, HCC incidence and HCC death as a further guard against baseline differences between attenders and non-attenders in risk profiles. Results of US screening for this high risk group found the mortality was lower by 24% (95% CI: ؊52 to 62%) in the attenders compared to the non-attenders. After adjustment for sensitivity, the mean sojourn time (MST) were 1.57 (95% CI: 0.94 -4.68) for subjects with liver cirrhosis and 2.66 (95% CI: 1.68 -6.37) years for non-cirrhotic patient. Significant increases in risk of HCC incidence were associated with increasing age, male gender, hepatitis B surface antigen positive (HbsAg), hepatitis C antibody positive (Anti-HCV), high levels of alanine transaminase (ALT) and alpha-fetoprotein (AFP) and a family history of HCC. Significantly increased risks of liver cirrhosis were associated with predictors of cirrhosis were increasing age, HbsAg, high levels of ALT and of AFP. Significant or borderline significant increases in risk of HCC death were associated with increasing age, male gender, HbsAg, high levels of AST and AFP. Adjusted for the significant variables, the mortality was lower by 41% (95% CI: ؊20 to 71%, p ‫؍‬ 0.1446) in the attenders compared to the non-attenders. The present study provides suggestive evidence on the efficacy of US screening in a selective high risk group in an endemic area of hepatitis B. A randomized controlled trial would yield definitive evidence. Within the protocol of such a trial, a shorter interscreening interval for patients with liver cirrhosis is suggested.

Impact of diabetes mellitus on incidence of hepatocellular carcinoma in chronic hepatitis C patients treated with interferon‐based antiviral therapy

“…33 Routine follow-up studies included clinical assessment, conventional biochemical tests and HCC screening using serum afetoprotein and ultrasonography. A new space-occupying lesion detected or suspected at the time of ultrasonography was further examined with computed tomography, selective hepatic angiography or fine needle aspiration biopsy.…”

Thrombocytopenia as a surrogate for cirrhosis and a marker for the identification of patients at high‐risk for hepatocellular carcinoma

“…1 Approximately 90% of patients with HCC in Taiwan 2 and in most parts or the world 3 have had chronic hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infection. A high-risk group that is limited to chronic HCV and HBV is ideal for designing a screening method.…”

“…In a community study from Taiwan, hepatitis B surface antigen (HBsAg), anti-HCV, aspartate aminotransferase (AST), alanine aminotransferase (ALT), AFP, and a family history of HCC were selected as markers for the identification of high-risk groups. 1,10,14,15 Twenty-nine percent of participants were identified as the high-risk group and were scheduled for US. 1,10 However, it is a daunting task to perform US on 29% of the adult population in a community.…”

“…1,10,14,15 Twenty-nine percent of participants were identified as the high-risk group and were scheduled for US. 1,10 However, it is a daunting task to perform US on 29% of the adult population in a community.…”

HCC surveillance: Who is the target population?

“…The index is useful to identify low-risk individuals but there is need for stratification within the high-risk subgroup that represents the most prevalent population in other areas where HCV is the major cause for cirrhosis, while HBV or alcohol are less frequent. In the study by Velazquez et al, all HCV cirrhotic patients belong to a high-risk cohort, but there is no doubt that it will be possible to stratify them according to the degree of risk and for this purpose the parameters identified in other investigations (AFP, 3,[6][7][8][9][10] proliferation rate, 15,16 irregular regeneration, 17 dysplasia, 18,19 and viral genotype [20][21][22] ) might become useful. The question is to what extent a different risk category (high vs. moderate) will change the entry of the patients into surveillance.…”