Weighing the benefits of hepatocellular carcinoma surveillance against potential harms

Figures & data

Table 1 Summary of current international guidelines on HCC surveillance

Guidelines	Surveillance population	Surveillance modality	Surveillance interval
AASLD 2018^Citation40	All patients with liver cirrhosis except patients with Child–Pugh stage C cirrhosis unless on transplant waiting list	US ± AFP	6 months
APASL 2017^Citation41	All patients with cirrhosis Chronic HBV carriers without cirrhosis • Asian females >50 years • Asian males >40 years • Africans >20 years • Family history of HCC	US + AFP	6 months
EASL 2018^Citation24	Cirrhosis Child–Pugh stage A and B Cirrhosis Child–Pugh stage C awaiting liver transplant Chronic HBV without cirrhosis at intermediate (10–17) or high risk (≥18) of HCC according to PAGE-B score Non-cirrhotic patients with Metavir F3 fibrosis regardless of etiology	US	6 months
ESMO 2018^Citation42	All patients with cirrhosis as long as liver function and comorbidities allow curative or palliative treatment Chronic HBV and HCV carriers with Metavir F3 fibrosis Asian chronic HBV carriers with serum HBV-DNA above 10,000 copies/mL	US ± AFP	6 months

Abbreviations: AASLD, American Association for the Study of Liver Disease; AFP, alpha fetoprotein; APASL, Asian Pacific Association for the Study of the Liver; EASL, European Association for the Study of the Liver; ESMO, European Society for Medical Oncology; HBV, hepatitis B virus; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; PAGE-B score, Platelets, Age, Gender, Hepatitis B; US, ultrasound.

Table 2 The benefits vs limitations and risks of HCC surveillance

Benefits of surveillance	Limitations and potential harms of surveillance
Allows diagnosis of HCC at an earlier stage	Limitations in study design of current evidence such as lack of randomized controlled trials and lead time bias
Reduces HCC mortality	Financial cost • Questionable cost-effectiveness • Cost to health care system • Cost to patients
Increases the rate of curative resection	Limitations of surveillance tests • US – operator dependent and sensitivity reduces in patients with central obesity • AFP – poor sensitivity and poor specificity leading to false-positive and false-negative results
US allows detection of other complications of cirrhosis such as ascites and portal vein thrombosis	Up to 5% of patients have false-positive results Harms of false-positive results • Radiation exposure with cross-sectional imaging • Contrast risk • Risk of invasive procedures such as liver biopsy • Psychosocial harm to patient and family
Unarguable value in well-defined target populations who have a high incidence of HCC and are fit for intervention	Although HCC in NAFLD without cirrhosis is increasingly common, the target population is so large, and the incidence within the population is so small, surveillance in NAFLD patients without cirrhosis is not cost-effective and is not advocated

Abbreviations: AFP, alpha fetoprotein; HCC, hepatocellular carcinoma; NAFLD, non-alcoholic fatty liver disease; US, abdominal ultrasound.

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