Importance of Surveillance Programs For Hepatocellular Carcinoma

Table 1 Survival benefit of surveillance programs for hepatocellular carcinoma (HCC) in retrospective studies

Surveillance of HCC has been rec-ommended by various organizations like AASLD and APASL. To mark the recent progress of HCC survelliance, Professor Deepak Amarapurkar, from Bombay Hospital & Medical Research Centro, Mumbai, India, presented a report on surveillance programs for hepatocellular carcinoma in a session held today. He said that hepatocellular carcinoma (HCC) is a common cancer world wide and a major public health problem in the Asia-Pacific region. HCC is a potentially viable target for surveillance as it occurs in a well-defined risk population (cirrhosis is a primary risk factor).Surveillance has been practiced widely by gastroenterologists and hepatologists all over the world and it has become a standard practice even though evidence of its benefits has not yet been clearly established. Alfa feto protein (AFP) and/or ultrasound examination have been used every six monthly for surveillance program.

Professor Amarapurkar pointed out that the usefulness of surveillance programs for early diagnosis of HCC in clinical practice has been shown in a number of studies. In five retrospective studies comparing HCC detected on surveillance when compared with the HCC detected without surveillance, small and potentially curable HCCs were detected in the surveillance groups. However this surveillance program did not improve prognosis in patients with advanced cirrhosis. In surveillance groups, HCCs detected are usually small and relatively uniform. HCC in the non-surveillance groups were large and varied. HCC in the non surveillance groups are detected in two different manners (1) asymptomatic discovered outside the regular surveillance program, and (2) symptomatic HCC detected without symptoms in non-surveillance groups were also smaller as compared to symptomatic group and the efficacy of surveillance program will be decided on the number of asymptomatic patients detected incidentally in non-surveillance group.

Professor Amarapurkar continued that cost effectiveness of surveillance programs depends critically on the rate of small HCCs detected accidentally in non-surveillance groups, annual incidence of HCC in various etiologies of HCCs and adoption of liver transplantation as a treatment strategy. Surveillance programs detect small tumors and allow application of curative studies. The incremental cost effective ratio for six monthly AFP and ultrasound varies between USD 24,500 to 46,600 per QALY. Surveillance for HCC has been widely adopted, but concrete evidence of cost effective benefit is not available. Though there have been more than 25 observational studies proving the superiority of surveillance programs over no surveillance, these studies have limitations of lead time bias, length bias for early diagnosis of small HCCs, difference growth rate of HCC and poor compliance of the surveillance program.

Table2 Cost-effectiveness models for hepatocellular carcinoma (HCC) surveillance

US: Ultrasound; AFP: Alpha-feto protein; CT: Computed tomography; MRI: magnetic resonance imaging; ICER: incremental cost-effective ratio;
QALY: Quality adjusted life years

Finally, he concluded that surveillance can be effective in reducing disease specific mortality with acceptable cost effectiveness among a select group of patients. Cost effectiveness depends on rates of (1) incidentally detected small HCC, (2) annual incidence of HCC, (3) adoption of transplant as a treatment strategy and (4) younger age of screen population. Conclusions from observational studies, computerized decision analytical models suggests that (1) ultrasound + AFP six monthly in a mixed etiology cohort is the most effective surveillance strategy, (2) cost effectiveness of surveillance strategy is dependent on etiology, (3) much more cost effective in HBV related cirrhosis and least effective in alcoholic cirrhosis.