Hepatocellular carcinoma (surveillance)

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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.

Rationale

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

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

  • 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 tumors.

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 .

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:

  • hepatitis B
    • men >40 years old
    • women >50 years 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 tumor is found.

Controversies
  • 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 randomized controlled trial in Western nations is low
  • data for CT or MRI as screening modalities have 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