Hepatocellular carcinoma (surveillance)

Hepatocellular carcinoma (HCC) surveillanceprograms have been adopted by some health systems.

Rationale

The idea behind HCC screening, as with any screening program, is to detect  cancerclinically silent cancer earlier when treatment should have a better prognosis.

Current recommendations

Current recommendations for surveillance derive from a 2004 randomized controlled trial conducted in China with patients with chronic hepatitis B¹.

• ultrasound exam + AFP serum test every 6 months

The group reported a 37% decrease in HCC 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 HCC (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.

Controversies

• the surveillance protocol from the experiment may not be generalizeable to other patient populations in the world, but the likelihood of being able to conduct a randomized controlled trial in Western nations is low⁶
• data for CT or MRI as screening modalities has not been well developed 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 HCC
  • AFP should never be the sole screening tool