Benefits and Harms of HCC Surveillance in Patients With Cirrhosis
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersBACKGROUND & AIMS
The value of a cancer screening programs is defined by its balance of benefits and harms; however, there are few data evaluating both attributes for hepatocellular carcinoma (HCC) surveillance. We aimed to characterize benefits and harms of HCC surveillance in a large prospective cohort of patients with cirrhosis.
METHODS
We conducted a secondary analysis of a clinical trial evaluating HCC surveillance among patients with cirrhosis at a safety-net health system enrolled between December 2014 and July 2015. We quantified surveillance-related benefits, defined as early HCC detection and curative treatment receipt, and physical harms, defined as diagnostic procedures for false positive or indeterminate results, over an 18-month period.
RESULTS
Of 614 cirrhosis patients with ≥1 surveillance exam, abnormal results were observed in 118 (19.2%) patients. Twenty-six patients developed HCC during follow-up, of whom 16 (61.5%) were detected by surveillance. The proportion of HCC detected at BCLC stage 0/A (62.5% vs 50%, p = .69) and who underwent curative treatment (43.8% vs. 40.0%, p = 1.0) did not significantly differ between surveillance-detected patients and those diagnosed incidentally/symptomatically. Physical harms were observed in 54 (8.8%) patients who underwent surveillance - most of mild severity with only 1 diagnostic CT or MRI and none undergoing invasive testing such as biopsy. Incidental findings on follow-up imaging were found in 40 (6.5%) patients -23 of low clinical importance and 17 medium clinical importance.
CONCLUSIONS
In our cohort of patients with cirrhosis, HCC surveillance was associated with high early tumor detection and minimal physical harms.
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Benefits and Harms of Hepatocellular Carcinoma Surveillance in a Prospective Cohort of Patients With Cirrhosis
Clin. Gastroenterol. Hepatol. 2021 Sep 01;19(9)1925-1932.e1, AG Singal, S Patibandla, J Obi, H Fullington, ND Parikh, AC Yopp, JA MarreroFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Hepatocellular carcinoma (HCC) is a common and dreaded complication of liver cirrhosis, with the value of surveillance in at-risk populations frequently debated.1 While surveillance has the potential to increase the detection of early-stage/ asymptomatic HCCs that can be treated curatively, this needs to be cost-effective and balanced against the potential harms of false-positive results. Singal et al., report an HCC incidence of 2.8% (26 HCCs in 614 patients over 18 months) in a carefully selected cohort of fit cirrhotic patients undergoing surveillance in a safety-net healthcare setting. Encouragingly, 62.5% were detected at an early stage (BCLC 0/A), with 44% offered curative therapy. Although the majority were detected by surveillance (16; 61.5%), there was no significant difference in early-stage detection between those detected by surveillance or those detected incidentally/presenting symptomatically (62.5% vs 50%) – possibly reflecting the lack of consistent formal surveillance during the study period, but also the setting in which the study was conducted, with relatively high numbers of visits to primary care providers.
Minimal ‘physical harms’ were reported, with 54 patients (8.8%) requiring additional scans consequent to a false positive surveillance result. These were largely attributed to false-positive findings on abdominal ultrasound scans (USS) – known to have greater sensitivity than specificity.2 Notably though, 4/16 HCCs in this series were detected by alpha-fetoprotein (AFP) alone, fueling further the debate of the role of USS alone versus USS+AFP as surveillance tools. The lack of ‘physical harms’ is highlighted in a positive fashion by the authors, although of course, these do not consider cost-effectiveness or the psychological and cost burdens to patients.
Perhaps the positive take-home messages here are: (1) fit patients with cirrhosis who are under regular follow-up by primary care or hepatology physicians, are more likely to have their HCC detected at an early stage - despite the relatively disappointing performance of formal HCC surveillance programs - coming to minimal physical harm; (2) there is room for major improvement.
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