Hepatocellular carcinoma (surveillance)
Hepatocellular carcinoma surveillance programs have been adopted by some health systems in attempts to effect an early diagnosis of hepatocellular carcinoma in high-risk populations.
The idea behind hepatocellular carcinoma screening, as with any screening program, is to detect clinically silent cancer earlier when treatment should have a better prognosis.
Current recommendations for surveillance derive from a 2004 randomised controlled trial conducted in China with patients with chronic hepatitis B 1:
- ultrasound exam + AFP serum test every 6 months
The group reported a 37% decrease in hepatocellular carcinoma mortality with this surveillance protocol, and this was attributed to early detection of tumours.
The six-month interval was based on the doubling time of hepatocellular carcinoma (median 4-6 months). Some data suggest that it is more optimal than a 3 month or 12-month interval 2,3.
AASLD and EASL guidelines
American Association for the Study of Liver Disease (AASLD) and the European Association for the Study of the Liver (EASL) promote ultrasound every 6 months if: 4,5
- hepatitis B
- men >40 years old
- women >50 year old
- Africans >20 years old and at time of diagnosis if there is a positive family history
- hepatitis C
- if stage 3 fibrosis
Surveillance is not recommended for patients who are too decompensated to benefit from therapy if a tumour is found.
- the surveillance protocol from the experiment may not be generalizable to other patient populations in the world, but the likelihood of being able to conduct a randomised controlled trial in Western nations is low 6
- data for CT or MRI as screening modalities has not been well developed
- unlike the original screening trial, AFP is not currently included in screening guidelines because of problems with sensitivity and specificity
- persistently increasing AFP or increasing AFP with stable AST are concerning for hepatocellular carcinoma
- AFP should never be the sole screening tool
- 1. Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular carcinoma. J. Cancer Res. Clin. Oncol. 2004;130 (7): 417-22. doi:10.1007/s00432-004-0552-0 - Pubmed citation
- 2. Santi V, Trevisani F, Gramenzi A et-al. Semiannual surveillance is superior to annual surveillance for the detection of early hepatocellular carcinoma and patient survival. J. Hepatol. 2010;53 (2): 291-7. doi:10.1016/j.jhep.2010.03.010 - Pubmed citation
- 3. Trinchet JC, Chaffaut C, Bourcier V et-al. Ultrasonographic surveillance of hepatocellular carcinoma in cirrhosis: a randomized trial comparing 3- and 6-month periodicities. Hepatology. 2011;54 (6): 1987-97. doi:10.1002/hep.24545 - Pubmed citation
- 4. Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53 (3): 1020-2. doi:10.1002/hep.24199 - Free text at pubmed - Pubmed citation
- 5. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J. Hepatol. 2012;56 (4): 908-43. Pubmed citation
- 6. Kulik LM, Chokechanachaisakul A. Evaluation and management of hepatocellular carcinoma. Clin Liver Dis. 2015;19 (1): 23-43. doi:10.1016/j.cld.2014.09.002 - Pubmed citation
- 7. Di Bisceglie AM, Sterling RK, Chung RT et-al. Serum alpha-fetoprotein levels in patients with advanced hepatitis C: results from the HALT-C Trial. J. Hepatol. 2005;43 (3): 434-41. Pubmed citation