Should Surveillance for Liver Cancer be Modified in Hepatitis C Patients After Treatment-related Cirrhosis Regression?

Roberta D'Ambrosio; Massimo Colombo


Liver International. 2016;36(6):783-790. 

In This Article

Should Surveillance be Modified in Cirrhosis Regressors?

Surveillance with 6-month US examination of the liver has been shown to provide survival benefits in patients with advanced HCV, however without providing an evidence-based determination of its economic consequences, in parallel.[31,33] A prediction of cost-effectiveness of surveillance for HCC relies on modelling, whereby surveillance with US of viraemic patients with cirrhosis appears to be cost-effective in those with an annual incidence of HCC equal or greater than 1.5%. AASLD practice guidelines for HCC recommend surveillance for SVR patients with a pretreatment diagnosis of cirrhosis, whereas cirrhosis regression should not be a reason to withhold surveillance.[31] Both EASL clinical practice guidelines for HCV and HCC recommend surveillance of SVR patients with advanced fibrosis;[33] in addition, guidelines for HCV recommend clinical assessment of SVR patients with pre-existing cofactors for liver disease like a history of alcohol drinking and/or type 2 diabetes, independently of pretreatment fibrosis stage. EASL acknowledges that the exact duration of surveillance in patients with advanced fibrosis or cirrhosis who achieve an SVR is unknown in the current state of knowledge, suggesting, however, that it is probably indefinite. All in all, both international societies advise maintaining surveillance for SVR patients with advanced liver fibrosis, independently of the histological response to therapy.

Interestingly, a recent Japanese study of HCC surveillance in SVR patients reported reduced survival rates among patients who discontinued follow-up after viral eradication.[66] Overall, the incidence of HCC was 3.4% during a mean 6-year follow-up period, and cirrhosis was detected in 36% of those who underwent surgical resection. In patients on regular follow-up, HCC displayed favourable clinical features, including small tumour size, single, no portal invasion and low tumour stage according to TNM staging at variance with what observed in patients escaping surveillance at the time of diagnosis. As a consequence, HCC patients under surveillance were in a better BCLC class (P < 0.0001), which granted for more chances of receiving a curative treatment (resection vs. no treatment: 51% vs. 30%) and a better survival (P < 0.0001). Interestingly, while reporting no differences in survival rates between groups, the authors found higher HCC recurrence rates in patients undergoing 6-month surveillance than those who received 3-month surveillance (P = 0.04).[66] One point that needs to be clarified is whether serum AFP, which was dropped in the surveillance of viraemic patients, may instead be useful to monitor HCC risk in SVR patients.[24,65] Recently, AFP emerged as a powerful baseline independent risk of HCC among a cohort of compensated cirrhotics, independently of their CPT class (HCC risk: AFP ≥10 vs. AFP <10 ng/mL: HR 7.19 (2.06–25.1); P = 0.002).[67]