Barriers to screening for HCC are ‘multiple and at different levels’
Hepatocellular carcinoma is the most common type of liver cancer worldwide. Individuals who have been diagnosed with hepatitis B, hepatitis C or cirrhosis have the highest risk for developing HCC. While the incidence rate decreased among younger and middle-aged adults between 1992 and 2015, the overall incidence rate of HCC in the United States increased from 4.1 cases per 100,000 people in 1992 to 9.5 in 2015.
Sammy Saab, MD, MPH, AGAF, FACG, FAASLD, medical director of the Pfleger Liver Institute and the Adult Liver Transplant Program, chief of Transplant Hepatology, professor of medicine and surgery, adjunct professor of nursing and professor (Hon) at California Northstate University College of Medicine, and associate editor for Liver, and Journal of Clinical Gastroenterology, spoke with Healio about screening for HCC. He highlighted the importance of regular screening, barriers to effective screening and individuals at the highest risk to develop HCC
Healio: Why is screening for HCC so important?
Saab: Screening is critical because it allows us to diagnose liver cancers at an earlier stage. By doing so, people then become candidates for potentially curative therapy. If you do not do screening, people will not know they have cancer until they present with symptoms like pain and jaundice. By that time, the cancer is very large and treatment options are extremely limited.
Healio: What is the hardest patient subgroup to screen and track?
Saab: The big gorilla in the room is going to be those patients with cirrhosis who are not diagnosed. The problem we have is that cirrhosis is not always easy to diagnose. The standard of care is anyone who has cirrhosis has to be screened for liver cancer with abdominal imaging, and possibly bloodwork, every 6 months. But if you have a patient who has undiagnosed cirrhosis, they will not be screened. As a consequence, they will present to the office of a hospital with very large tumors. Those patients who are screened can be found with small tumors.
Other populations very difficult to screen are those individuals who have hepatitis C and have been cured. These people hear the word cure, and they think they are free of all liver complications, but if they had underlying cirrhosis, those individuals still are at a risk for liver cancer.
The other group that we are worried about are people who are very obese because the ultrasound may not be sufficient to penetrate deeper into the liver to look for any small tumors.
Healio: What role does transplantation have in HCC management?
Saab: Liver transplant plays a major role because we are actually dealing with two disease processes, not just one. Liver cancer arises from dirty soil from a cirrhotic liver. But treating liver cancer with local regional therapy may be temporary because the rest of the liver that is still there has cirrhosis. These patients may be at risk for new cancers popping up afterward.
Liver transplantation offers opportunity to not just treat the liver cancer, but to remove the setting or the soil where the cancer first arose from. Liver transplantation is considered to be a curative treatment for people with liver tumors.
Healio: Can you explain the importance of screening patients with HCV who have already reached sustained virologic response?
Saab: Sustained virologic response means that someone has been cured of hepatitis C. By curing hepatitis C, the idea is that people live longer and better. But these individuals who are cured may have underlying cirrhosis. So, although curing hepatitis C will make the liver work better and, in people with cirrhosis, will decrease the risk for developing cancer, it does not eliminate the risk for liver cancer.
Therefore, if someone has cirrhosis and they are cured, they still need to be screened for liver cancer on a regular basis. Unfortunately, both physicians and patients when they hear the word cure, they think that they are done with any kind of screening. But the reality is that if the patient has underlying cirrhosis, which was diagnosed before therapy, the patient needs to be screened for the rest of their life.
Healio: What challenges or barriers are there to screening for HCC?
Saab: There are actually a number of barriers and these could be stratified into system problems, patient barriers or doctor barriers. In terms of doctors, they may not recognize when someone has cirrhosis and are eligible for screening, or they may forget to order screening for liver cancer. In terms of patients, they may also fail to follow up with screening ultrasounds for cancer or the patient may say, “I have been cured of hepatitis C, I do not need to have any other treatments or follow ups.” The patient may also say, “Listen, I am asymptomatic, I do not want to pursue screening because I feel fine.” In terms of system problems, the office may not have a system to follow patients for regular screening, or they may have issues with insurance companies getting authorization for screening.
The barriers for screening, unfortunately, are multiple and at different levels.
- Cancer Center. Liver cancer types. https://www.cancercenter.com/cancer-types/liver-cancer/types. Accessed April 7, 2020.
- Rich NE, et al. Clin Gastroenterol Hepatol. 2019;doi:10.1016/j.cgh.2019.04.043.