It remains uncertain whether systematic screening for hepatocellular carcinoma leads to a survival advantage in patients with chronic liver disease, according to data from a systematic review published in Annals of Internal Medicine.
“Although screening identifies patients with early-stage [hepatocellular carcinoma] and some patients do well with curative therapy, there is very low-strength evidence from which to draw conclusions about the balance of benefits and harms of screening for [hepatocellular carcinoma],” researchers from Portland Veterans Affairs Medical Center and Oregon Health & Science University wrote.
The review included 22 relevant studies including trials and observational studies. In the two randomized controlled trials, researchers compared the effects of screening and not screening for hepatocellular carcinoma (HCC) on mortality, mainly among patients with hepatitis B. However, the researchers said both studies had significant limitations and risk for bias. Two additional trials compared different ultrasonography screening intervals and found no difference in HCC mortality.
In 18 observational studies, survival was compared between patients who had HCC detected by screening and patients who had HCC detected incidentally. Most of the studies included patients with hepatitis B or hepatitis C with cirrhosis. Although the general findings were that HCC was found at an earlier stage among those who were screened and survival was higher, the researchers cited methodological flaws of the studies as well as potential for bias.
“There is very low-strength evidence … about the effects of HCC screening on mortality in high-risk patients with chronic liver disease,” the researchers wrote. “There is limited evidence from which to draw firm conclusions about the balance of health outcome benefits and harms of using routine screening to identify HCC.”
In an accompanying editorial, David Atkins, MD, MPH, David Ross, MD, PhD, MBI, and Michael Kelley, MD, of the Veterans Health Administration, said in high-risk groups, including those with hepatitis C, the risk for HCC ranges from 10% to 65% and the 5-year survival with HCC is less than 10% in the absence of screening. It is also debated whether a randomized trial can be conducted to answer the question of whether early detection would improve the survival, when the patients already have underlying liver disease that may shorten survival even if cancer is cured.
“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 wrote. “Screening has a much greater potential to produce benefits exceeding harms in the highest-risk patients, such as those with hepatitis C and cirrhosis, than in the general population. Most important, we should pair any screening with efforts to collect better data, including baseline characteristics and long-term outcomes in screened and unscreened patients, which may help reduce our uncertainty.”
For more information:
Atkins D. Ann Intern Med. 2014;doi:10.7326/M14-1344.
Kansagara D. Ann Intern Med. 2014;doi:10.7326/M14-0558.