• Should We Screen for HCC?

Should We Screen for HCC?

Screening patients with cirrhosis for hepatocellular carcinoma (HCC) by abdominal ultrasonography (USS) and/or measurement of serum level of alpha-fetoprotein (AFP) is not associated with reduced mortality from this cancer, reseachers report from a matched case–control study in the October issue of Gastroenterology.

Schematic representation of the case–control study design, illustrating the criteria used to match cases (fatal HCC) to controls, the index date, and the DPP (the period before the index date during which the authors documented the occurrence of screening USS or serum AFP).

Patients with cirrhosis have a high risk (1%–8% per year) of HCC. Liver societies recommend screening patients with cirrhosis by USS, with or without tests for serum level of AFP every 6 months, whereas the National Cancer Institute does not.

It is unclear whether HCC screening decreases cancer-related mortality in patients with cirrhosis.

Andrew M. Moon et al performed a matched case–control study to evaluate the extent to which screening for HCC with USS or by serum level of AFP would be associated with decreased HCC-related mortality in patients with cirrhosis in the Veterans Affairs (VA) health administration.

Moon et al identified 238 patients who died of HCC and an equal number of matched controls with cirrhosis who did not die of HCC, and collected data on USS examinations and AFP tests, as well as medical records.

In unadjusted and adjusted analyses, the frequency of both ultrasound examination and AFP testing within 4 years of diagnosis were similar between groups, indicating no benefit of routine testing. There was no difference between cases and controls in the proportion who underwent screening USS (52.9% vs 54.2%; odds ratio, 0.95), screening for serum AFP (74.8% vs 73.5%; odds ratio, 1.07), or screening USS or AFP (81.1% vs 79.4%; odds ratio, 1.12) within 4 years before the index date.

As the authors pointed out, because of the widespread use of surveillance, a definitive large-scale randomized controlled trial seems unlikely to be conducted, so surveillance decisions will have to be based on the results of less-powerful study designs.

Moon et al encourage additional case–control studies to evaluate the efficacy of screening for HCC in other health care systems, in which available records are sufficiently detailed to enable identification of the indication for USS and AFP tests.

In an editorial that accompanies the article, Gregory S Cooper states that although the overall use of ultrasound examination and AFP was comparable with that of previous studies, we don’t know whether patients underwent a 1-time screen or were placed in an organized program. Also, he says that there is more value in measuring changes in AFP levels than a single static value.

Cooper explains that other researchers have proposed risk-based screening strategies that incorporate additional information on HCC risk factors, such as older age, male sex, viral etiology of liver disease, biomarkers, and genetic factors. Patients who are deemed at greatest risk could be screened with more sensitive imaging technologies, such as MRI.

Cooper reminds readers that a similar approach revealed the limitations of colonoscopy in the prevention of death from right-sided colon cancers, leading to the use of endoscopic techniques to better visualize the proximal colon. Although it is premature to abandon what has become the standard of care, future innovations in HCC surveillance could improve outcomes from this common and fatal cancer.

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