Does Hepatocellular Carcinoma Surveillance Increase Survival in At-Risk Populations? Patient Selection, Biomarkers, and
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INVITED REVIEW
Does Hepatocellular Carcinoma Surveillance Increase Survival in At‑Risk Populations? Patient Selection, Biomarkers, and Barriers Lisa X. Deng1 · Neil Mehta2
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Hepatocellular carcinoma (HCC) is a highly morbid and prevalent cancer globally. While high quality evidence for mortality benefit of HCC surveillance is lacking, early detection of HCC is likely beneficial as prognosis is highly correlated with tumor stage. High risk populations, including patients with cirrhosis and subgroups with Hepatitis B, should undergo surveillance with ultrasound ± alpha-fetoprotein (AFP) at 6-month intervals. In addition, emerging data suggest that patients with Hepatitis C cirrhosis who achieve sustained virologic response should continue surveillance. Further research is needed to determine the value of surveillance in patients with nonalcoholic fatty liver disease in the absence of cirrhosis or with advanced fibrosis of other etiologies. Newer biomarkers and models such as Lens culinaris agglutinin-reactive fraction of AFP, des-γ-carboxy prothrombin, and the GALAD score are increasingly utilized in the diagnosis and prognostication of HCC. The role of these biomarkers in surveillance is still under investigation but may potentially offer a more practical alternative to traditional image-based surveillance. Despite recommendations from multiple professional society guidelines, many at-risk patients do not receive HCC surveillance due to barriers at the patient, clinician, and health care system levels. Strategies such as implementing patient navigation services, educating clinicians about surveillance guidelines, and creating automated outreach systems, may improve surveillance rates and ultimately reduce morbidity and mortality from HCC. Keywords Hepatocellular carcinoma · Alpha-fetoprotein (AFP) · Mortality · Screening · Des-γ-carboxy prothrombin (DCP) Abbreviations AFP Alpha-fetoprotein DAA Direct-acting antiviral DCP Des-γ-carboxy prothrombin HCV Hepatitis C virus HCC Hepatocellular carcinoma AFP-L3 Lens culinaris agglutinin-reactive fraction of AFP NAFLD Nonalcoholic fatty liver disease NASH Nonalcoholic steatohepatitis OR Odds ratio RCT Randomized control trial SVR Sustained virologic response * Neil Mehta [email protected] 1
Department of Medicine, University of California, San Francisco, USA
Division of Gastroenterology, Department of Medicine, University of California, 513 Parnassus Avenue, Room S‑357, San Francisco, CA 94143‑0538, USA
2
Introduction Hepatocellular carcinoma (HCC) is globally the sixth most common cancer and fourth leading cause of cancer-related death [1]. In USA, the incidence and mortality of HCC continue to increase annually [2]. Prognosis for HCC is highly correlated with tumor stage. Early diagnosis is associated with a 5-year mortality of more than 70%, compared with 40 years Asian females > 50 years Family history of HCC African and/or North American blacks
Modality
Ultrasound
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