June 18, 2012 — A new study finds that the risk for mortality from hepatocellular carcinoma (HCC) among patients with alcoholic cirrhosis is not as great as had been thought, and that surveillance would not likely be cost-effective. The report was published in the June 18 issue of the Annals of Internal Medicine.
Alcoholic cirrhosis has long been associated with elevated risk for HCC. Surveillance for the cancer has been recommended to detect the condition at earlier, presymptomatic stages, when response to treatment is more likely, but the effect of such surveillance on mortality has not been adequately assessed.
Past estimates of the risk for a patient with alcoholic cirrhosis developing HCC range from 1% to 16%. In the United States, guidelines establish the threshold for cost-effectiveness in HCC surveillance at a risk of 1.5% per year. The investigators determined that the 5-year cumulative risk of HCC was only 1.0% among patients with alcoholic cirrhosis.
Peter Jepsen, MD, PhD, and colleagues from the University of Copenhagen and Aarhus University Hospital conducted a nationwide historical cohort study using registry data on 8482 patients who were diagnosed for the first time with alcoholic cirrhosis, from 1993 to 2005, to assess HCC incidence and mortality from 1 year postdiagnosis. The researchers also calculated the ratio of HCC-related mortality to total mortality. They restricted the data to a year after the cirrhosis diagnosis because many patients may already have had HCC at the time of diagnosis of alcoholic sclerosis. HCC incidence rate in the first year after cirrhosis diagnosis was 9.8 (95% confidence interval [CI], 7.9 - 12.0) per 1000 person-years compared with 3.8 (95% CI, 2.6 - 5.4) per 1000 person years in the second year.
Of the 8482 participants, 169 developed HCC, 5734 died, and 151 of those who died (1.8%) had HCC. The 5-year cumulative risk for HCC was 1.0% (95% confidence interval, 0.8% - 1.3%), and the cumulative mortality risk was 43.7% (95% CI, 42.6% - 44.7%).
Limitations of the study included lack of uniformity of clinical diagnostic criteria (although the researchers do not doubt the accuracy of the diagnoses) and use of registry data that did not include detailed accounts of clinical care. A randomized trial to address efficacy of HCC surveillance would provide more telling data, but would not be ethical, the researchers write.
"Our findings indicate that HCC incidence among Danish patients with alcoholic cirrhosis is far below the currently accepted 1.5% threshold for cost-effective surveillance," the investigators conclude.
The authors have disclosed no relevant financial relationships.
Ann Int Med. 2012;156:841-848.
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Cite this: Liver Cancer Death Unlikely in Alcoholic Sclerosis - Medscape - Jun 18, 2012.