Regular Surveillance for Hepatocellular Carcinoma Improves Survival

Katherine Kahn, DVM

July 31, 2006

July 31, 2006 (Boston) — Routine surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis results in earlier diagnosis of HCC, improves access to liver transplantation, and improves survival times, a new study reveals. Richard Stravitz, MD, associate professor of medicine in hepatology at the Virginia Commonwealth University in Richmond, presented the findings here at the World Transplant Congress.

"Before liver transplantation there wasn't much you could do with a diagnosis of HCC," Dr. Stravitz told Medscape. "Now that we have liver transplantation, the question is whether surveillance detects cancers earlier so that we can transplant patients and have improved outcomes."

To examine this further, Dr. Stravitz and coinvestigators retrospectively reviewed the records of 296 patients with cirrhosis and HCC that had been diagnosed and treated between 1997 and 2005 at the Virginia Commonwealth University Medical Center and its Veterans Affairs affiliate. Of these patients, 86% were men, 62% were white, and 76% were younger than 65 years.

The researchers assigned patients to 1 of 3 groups, representing different levels of quality of surveillance. The standard-of-care surveillance group included patients who had received an ultrasound or other abdominal imaging at least once in the year prior to HCC diagnosis. The substandard surveillance group included patients who were known to have cirrhosis but did not undergo imaging in the year prior to a HCC diagnosis. The unrecognized cirrhosis group included patients who received no surveillance prior to a HCC diagnosis.

The majority of patients (63%) had underlying hepatitis C as the cause of cirrhosis, with 41% having alcohol abuse as a contributing factor in addition to hepatitis C. Eleven percent had alcoholic cirrhosis and 10% had nonalcoholic steatohepatitis or cryptogenic cirrhosis. Nine percent had cirrhosis from other causes, and 7% had cirrhosis from hepatitis B virus.

Half of the patients had stage I (9%) and stage II (41%) HCC at time of diagnosis, while half had stage III (19%) and stage IV (31%) HCC.

The quality of surveillance was strongly linked to tumor stage at diagnosis. Whereas almost 70% of patients who underwent standard-of-care surveillance had stage I or II HCC at initial diagnosis, only 35% of those who received substandard surveillance had stage I or II. "Still, even substandard surveillance was better than no surveillance, since fewer than 20% of patients with unrecognized cirrhosis had HCC within Milan criteria at diagnosis," Dr. Stravitz said during his presentation.

Not surprisingly, survival was closely linked with the tumor stage at diagnosis, with mean survival for stage I patients near 60 months and decreasing to a mean of 26 months for stage II, 14 months for stage II and 5 months for stage IV.

Quality of surveillance also significantly correlated with whether a patient underwent liver transplantation. While 32% of the standard-of-care group received liver transplants, 13% of the substandard surveillance group and 7% of the group that had no surveillance received liver transplants (P < .001).

Those patients who underwent liver transplantation (n = 60) had a much greater increase in mean survival time compared with those who did not receive liver transplants (n = 205), with 81% of those receiving transplants having a mean survival of 3 years vs 12% for those not transplanted (P < .001).

Survival also correlated significantly with quality of surveillance. "Mean 3-year survival in patients who received standard-of-care surveillance was 40% as compared to 27% in those with substandard surveillance, but only 12% in patients with unrecognized cirrhosis," Dr. Stravitz said.

Session cochair William Chapman, MD, commented to Medscape, "Even in our best medical centers, surveillance programs fail frequently. Even among transplant centers and physicians that treat patients with liver disease, we do not have a systematic approach to surveillance." Dr. Chapman is chief of the abdominal transplantation section at Washington University School of Medicine in St. Louis, Missouri.

"The big deal is catch them early so they are still candidates for a curative therapy which is transplantation," said Alan Hemming, MD, session cochair and chief of the division of transplantation and hepatobiliary surgery at the University of Florida in Gainesville. "But it's hit or miss — even in our program. Although we apply set criteria and patients get screened at set intervals, that interval may not be adequate."

Dr. Stravitz and colleagues were surprised to find that more than 80% of patients who did not receive surveillance did have laboratory markers for cirrhosis that went unrecognized. "The bottom line is if a physician sees laboratory abnormalities in a patient such as thrombocytopenia, low platelet count, an AST/ALT ratio of greater than 1 — and these may be subtle — then that patient needs to be referred for surveillance," he told Medscape.

The study was independently funded. The authors report no relevant financial relationships.

World Transplant Congress 2006: Abstract 776. Presented July 26, 2006.


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