HCC screening advised for high-risk patients with chronic liver disease

By Lorraine L. Janeczko

NEW YORK (Reuters Health) - Screening can identify early-stage hepatocellular carcinoma (HCC) in patients with chronic liver disease, but whether screening yields a survival advantage over clinical diagnosis is uncertain, new research suggests.

"While we say that the strength of evidence is very low, we don't recommend against screening," said principal investigator Dr. Devan Kansagara of the Portland Veterans Affairs Medical Center in Portland, Oregon, by phone with Reuters Health. "We just clarify the strength of evidence. This is an important distinction."

"Whether or not patients should be screened depends on many things. . . . It's important to make sure that the program targets the higher-risk people and avoids people who might not benefit from screening. We hope clinicians will discuss clinical care and share decision making with their patients," he said.

To better understand the benefits and harms of routine HCC screening compared with clinical diagnosis in patients with chronic liver disease, the authors reviewed the published English-language clinical trials and observational studies and reported their findings online June 17 in Annals of Internal Medicine.

Of 13,801 citations, the authors eliminated studies that did not meet their inclusion criteria, such as those of patients with prior, advanced, or metastatic HCC, and chose 22 primary studies. They found that the overall strength of evidence on the effects of screening was very low.

Co-author Dr. Janice H. Jou, also of the Portland Veterans Affairs Medical Center, said by phone, "There is not adequate level-1 evidence published in the literature to be able to draw a conclusion."

"There are very few randomized trials in this area. The biggest opportunity presented by our findings is to create opportunities for future study in this area. It's a way to start a conversation and a discourse about what are the next steps to investigate this area," she said.

"Patients who have early stage disease can be treated with very effective therapies and their overall survival can be improved. We should do better studies to identify who those patients are," she said.

Dr. Yuman Fong of City of Hope in Duarte, California, said by phone, "I don't think our screening methods now are perfect, and I don't think most of our small tumors are being treated correctly. That's why, when you look at the studies over a long period of time, the conclusion is that it probably didn't change very much. It doesn't surprise me."

"In reality, in the best of medical worlds that we currently already have the technology for, we would be picking those people at high risk, screening them with a short-sequence scan that can find cancer and distinguish it from the non-cancerous nodules and either laparoscopically or robotically remove small pieces of liver for the cancer or kill it with a needle as an outpatient procedure," he said.

"It is not right to not screen," he added. "The chance of finding cancer is very high in this patient population: 5% per year of cancer. The questions are how to screen and how to treat the cancer once you find it. These are the bigger questions, not whether we should screen or not."

"It is important for these people to be seen and blood tests to be drawn because now our treatments for hepatitis B and C are so good," he said.

Dr. Fong, who was not involved in the study, advised that "we should be designing selective scan sequences that take less time on the scanner, are less taxing to the patients and less costly. The cost has been stopping us from using the best technology we have. We're using sonography because it's much lower cost."

In an editorial, Drs. David Atkins, David Ross and Michael Kelley of the Veterans Health Administration in Washington, DC, write, "Although we agree that current screening should not be expanded and new screening programs should not be initiated, the range of uncertainty includes a clinically important benefit of screening."

They write that, in the highest-risk patients, including those with hepatitis C cirrhosis, screening has a much greater potential to produce benefits that exceed harms than it does in the general population.

"It is appropriate to allow clinicians caring for these patients to continue to offer screening, but offers should be targeted to those who are good candidates for treatment and should include a shared decision-making approach that explicitly acknowledges the limitations of the evidence," they write.

SOURCE: http://bit.ly/1o29kw2

Ann Intern Med 2014.