Hepatocellular carcinoma surveillance programs have been adopted by some health systems in attempts to effect an early diagnosis of hepatocellular carcinoma in high-risk populations.
Rationale
The idea behind hepatocellular carcinoma screening, as with any screening program, is to detect clinically silent cancer earlier when treatment should have a better prognosis.
Recommendations
Recommendations for surveillance derive from a 2004 randomized controlled trial conducted in China with patients with chronic hepatitis B 1:
ultrasound exam + AFP serum test every 6 months
The group reported a 37% decrease in hepatocellular carcinoma mortality with this surveillance protocol, and this was attributed to early detection of tumors.
The six-month interval was based on the doubling time of hepatocellular carcinoma (median 4-6 months). Some data suggest that it is more optimal than a 3 month or 12-month interval 2,3.
AASLD and EASL guidelines
American Association for the Study of Liver Disease (AASLD) and the European Association for the Study of the Liver (EASL) promote ultrasound every 6 months, if: 4,5
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men >40 years old
women >50 years old
Africans >20 years old and at time of diagnosis if there is a positive family history
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if stage 3 fibrosis
Surveillance is not recommended for patients who are too decompensated to benefit from therapy if a tumor is found.
Controversies
the surveillance protocol from the experiment may not be generalizable to other patient populations in the world, but the likelihood of being able to conduct a randomized controlled trial in Western nations is low 6
data for CT or MRI as screening modalities have not been well developed
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unlike the original screening trial, AFP is not included in screening guidelines because of problems with sensitivity and specificity
persistently increasing AFP or increasing AFP with stable AST are concerning for hepatocellular carcinoma
AFP should never be the sole screening tool
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