Hepatocellular carcinoma is the most common primary liver cancer, occurring largely in patients with cirrhosis. The incidence of hepatocellular carcinoma is rising in the US, as is its mortality, making hepatocellular carcinoma one of the leading causes of cancer-related deaths in the country.1 Despite the fact that early detection improves survival in patients with hepatocellular carcinoma, biannual screening with ultrasonography has not been widely adopted by physicians in the US.2, 3 This is likely due to the limited amount of data from the US demonstrating its benefit.
In this issue, Singal et al provide much needed “real world” data to support the notion that screening for hepatocellular carcinoma in patients with cirrhosis is indeed advantageous. By retrospectively analyzing data from 374 patients diagnosed with hepatocellular carcinoma in 4 US health systems, they were able to show that patients with hepatocellular carcinoma detected by screening had an earlier tumor stage at the time of diagnosis, as well as improved survival when compared with patients with hepatocellular carcinoma that was detected incidentally or symptomatically. Screened patients were also more likely to receive curative treatments for their hepatocellular carcinoma that included local ablative therapy, surgical resection, or transplantation.
While these results are compelling, the authors report other data that we should recognize because they identify potential deficiencies in our current management practices. Of the hepatocellular carcinoma cases included in the study, only a minority (42%) were actually detected by screening. Also, the majority of the patients had not received specialty care from a hepatologist in the year prior to diagnosis, a factor that significantly increased the likelihood that hepatocellular carcinoma was detected by screening. Most concerning, however, is the fact that only a small proportion of hepatocellular carcinoma patients (20%) received a potentially curative therapy, including just 34.6% of those with early-stage disease. This suggests that the majority of patients with cirrhosis are not receiving the health care measures that would likely improve their survival by detecting hepatocellular carcinoma at an early stage and by providing curative therapies once hepatocellular carcinoma is recognized. So, how do we change the current culture so that providing the appropriate screening tests and curative therapies in this patient population is associated with quality care?
Firstly, we must increase awareness among physicians that hepatocellular carcinoma screening is indeed beneficial for patients with cirrhosis. Until a reliable blood test is developed that is able to detect hepatocellular carcinoma (a task that alpha-fetoprotein alone fails to provide), biannual ultrasound appears to be our best option. Also, the role of the hepatologist in managing patients with cirrhosis must be addressed. As was identified in this study, patients with hepatocellular carcinoma that received hepatology subspecialty care in the year prior to diagnosis were far more likely to have been detected by screening than were those without hepatology care (80% vs 20%, respectively). However, in the US, primary care physicians provide the greatest amount of care for patients with cirrhosis, as only 20%-40% of cirrhotic patients are managed by a hepatology-trained subspecialist.4It is also not conceivable that hepatologists will be able to take on the entirety of the care for all patients with cirrhosis, given the rising burden of chronic liver disease. Instead, there must be a coordinated approach between primary care physicians and hepatologists to optimize screening in this population. However, no measure of collaboration will ultimately prove to be beneficial if the appropriate treatments are not provided for early-stage tumors that screening, it is hoped, would detect. Clearly, there is still much more work that needs to be done.
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-David G. Koch, MD, MSCR
This article originally appeared in the September 2017 issue of The American Journal of Medicine.
This is another article published earlier this month about a similar topic.
