Usefulness of Surveillance Programmes for Early Diagnosis of Hepatocellular Carcinoma in Clinical Practice

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FULL TEXT: http://www.medscape.com/viewarticle/575922?src=mp & spon=20 & uac=31238BR

From Liver International

Usefulness of Surveillance Programmes for Early Diagnosis of Hepatocellular

Carcinoma in Clinical Practice

Posted 07/11/2008

Pascual; Irurzun; Pedro Zapater; José Such; Sempere,;

Carnicer; María Palazón; Pedro de la Iglesia; Santiago Gil;

Francisco de España; -Mateo

Abstract and Introduction

Abstract

Background/Aims: Surveillance programmes (SPs) for hepatocellular carcinoma

(HCC) in patients with cirrhosis intend to diagnose the tumour in its early

stages when an effective therapy can be applied. The aims of this study have

been to compare the survival of patients with HCC being diagnosed or not in SPs,

and to establish a more accurate profile of the best target population.

Methods: From January 1996 to June 2005, 290 patients with HCC were included.

The relationship between being diagnosed or not in an SP and survival has been

analysed in a univariate analysis. Pretreatment variables found to be

significant predictors of survival in univariate analysis were included in a

multivariate analysis.

Results: The mean survival for patients diagnosed in SPs (27 months, 16.6-37.4)

was significantly longer than in patients being diagnosed out of these

programmes (6 months, 2.6-9.4) (P=0.001). Child-Pugh class A [β 1.4, 95%

confidence interval (CI) 1.14-1.78; P=0.0002] and being diagnosed in SPs (β

0.4, 95% CI 0.3-0.6; P=0.0003) became the only independent predictive factors of

longer survival.

Conclusions: SPs for HCC allow the detection of small tumours and the

application of intention-to-cure therapies, which improves survival. However,

these programmes do not improve prognosis in patients with advanced cirrhosis.

Introduction

Hepatocellular carcinoma (HCC) is the fifth most common neoplasm in the world

and is an important public health problem, especially in countries with a high

incidence of hepatitis B virus infection (Asian and African areas). However, an

increasing incidence of HCC has been reported in western developed countries in

the last few years, likely because of the high incidence of HCV infection, and

it is estimated that the number of new cases in the following years will be even

higher.

The prognosis of patients with HCC is poor when diagnosed in the presence of an

advanced disease but when diagnosed and treated for early stages, the 5-year

survival may reach 70-80%, and therefore the best strategy of surveillance

programmes (SPs) intends to diagnose HCC in these stages. Two main aspects make

these programmes easily applicable: first, the target population is easily

identifiable (patients with cirrhosis) and the tests most commonly used for HCC

detection [ultrasound examination and α-foetoprotein (AFP)] are widely

available. In fact, most physicians dedicated to attending patients with

cirrhosis agree that SPs are useful for early detection of HCC and have been

applying these programmes to patients.[1-3] The European Association for the

Study of the Liver (EASL) Conference on clinical management of HCC concluded

that surveillance is useful in Child-Pugh A patients. In Child-Pugh B and C

patients, though, surveillance is only justified if the patient may be a

candidate for liver transplantation.[4] The recently published guidelines for

management of HCC by the American Association for the Study of Liver Diseases

(AASLD) recommend the application of SP to patients at a high risk of developing

HCC, which includes patients with cirrhosis and some hepatitis B virus carriers

without established cirrhosis.[5] In both guidelines, the surveillance tools

recommended are ultrasonography (US) associated or not with AFP serum levels,

and the suggested interval period ranges from 6 to 12 months.

A recently published review regarding screening practice disclosed the reasons

for considering HCC a good candidate for SP.[6] First, the disease must be

common (HCC is the fifth neoplasm in the world), with substantial morbidity and

mortality, and the target population must be identifiable (at present, HCC is

the first cause of death in patients with cirrhosis and the annual incidence

ranges from 1 to 4%).[2-4] The surveillance test must have low morbidity, high

sensitivity and specificity, the test must be acceptable for the target

population and the surveillance intervals must be known. Both US and serum

levels of AFP are relatively easy to perform and especially US has a high

sensitivity (71-78%) and specificity (93%) and the optimal interval is 6-12

months.[1] Currently, there is not enough information to recommend a reduction

in this interval for patients at a higher risk of HCC or for using CT scanning

as a screening test. There must be a standardized plan for subsequent evaluation

of patients found to have a new lesion in the liver detected by US surveillance.

An algorithm for investigation of a nodule in this situation was proposed in the

EASL conference and modified in the recent AASLD practice guidelines, although

none of them have been evaluated prospectively. Moreover, there is an acceptable

and effective therapy (surgery, liver transplant and percutaneous therapy),

especially if the diagnosis is made at an early stage. Unfortunately, only a

minority of patients diagnosed with HCC have tumours amenable to performing a

potentially curative therapy.

Many unresolved questions in SP for the diagnosis of HCC remain, especially

regarding the real impact of early detection on survival of the best target

population.[7-11] The aim of this study has been to compare the clinical

characteristics and survival of patients with HCC being diagnosed or not in SP

in order to establish a more accurate profile of the best target population and

to evaluate the usefulness of these programmes in terms of survival in clinical

practice.

_________________________________________________________________

With Windows Live for mobile, your contacts travel with you.

http://www.windowslive.com/mobile/overview.html?ocid=TXT_TAGLM_WL_mobile_072008

[Guest guest]

FULL TEXT: http://www.medscape.com/viewarticle/575922?src=mp & spon=20 & uac=31238BR

From Liver International

Usefulness of Surveillance Programmes for Early Diagnosis of Hepatocellular

Carcinoma in Clinical Practice

Posted 07/11/2008

Pascual; Irurzun; Pedro Zapater; José Such; Sempere,;

Carnicer; María Palazón; Pedro de la Iglesia; Santiago Gil;

Francisco de España; -Mateo

Abstract and Introduction

Abstract

Background/Aims: Surveillance programmes (SPs) for hepatocellular carcinoma

(HCC) in patients with cirrhosis intend to diagnose the tumour in its early

stages when an effective therapy can be applied. The aims of this study have

been to compare the survival of patients with HCC being diagnosed or not in SPs,

and to establish a more accurate profile of the best target population.

Methods: From January 1996 to June 2005, 290 patients with HCC were included.

The relationship between being diagnosed or not in an SP and survival has been

analysed in a univariate analysis. Pretreatment variables found to be

significant predictors of survival in univariate analysis were included in a

multivariate analysis.

Results: The mean survival for patients diagnosed in SPs (27 months, 16.6-37.4)

was significantly longer than in patients being diagnosed out of these

programmes (6 months, 2.6-9.4) (P=0.001). Child-Pugh class A [β 1.4, 95%

confidence interval (CI) 1.14-1.78; P=0.0002] and being diagnosed in SPs (β

0.4, 95% CI 0.3-0.6; P=0.0003) became the only independent predictive factors of

longer survival.

Conclusions: SPs for HCC allow the detection of small tumours and the

application of intention-to-cure therapies, which improves survival. However,

these programmes do not improve prognosis in patients with advanced cirrhosis.

Introduction

Hepatocellular carcinoma (HCC) is the fifth most common neoplasm in the world

and is an important public health problem, especially in countries with a high

incidence of hepatitis B virus infection (Asian and African areas). However, an

increasing incidence of HCC has been reported in western developed countries in

the last few years, likely because of the high incidence of HCV infection, and

it is estimated that the number of new cases in the following years will be even

higher.

The prognosis of patients with HCC is poor when diagnosed in the presence of an

advanced disease but when diagnosed and treated for early stages, the 5-year

survival may reach 70-80%, and therefore the best strategy of surveillance

programmes (SPs) intends to diagnose HCC in these stages. Two main aspects make

these programmes easily applicable: first, the target population is easily

identifiable (patients with cirrhosis) and the tests most commonly used for HCC

detection [ultrasound examination and α-foetoprotein (AFP)] are widely

available. In fact, most physicians dedicated to attending patients with

cirrhosis agree that SPs are useful for early detection of HCC and have been

applying these programmes to patients.[1-3] The European Association for the

Study of the Liver (EASL) Conference on clinical management of HCC concluded

that surveillance is useful in Child-Pugh A patients. In Child-Pugh B and C

patients, though, surveillance is only justified if the patient may be a

candidate for liver transplantation.[4] The recently published guidelines for

management of HCC by the American Association for the Study of Liver Diseases

(AASLD) recommend the application of SP to patients at a high risk of developing

HCC, which includes patients with cirrhosis and some hepatitis B virus carriers

without established cirrhosis.[5] In both guidelines, the surveillance tools

recommended are ultrasonography (US) associated or not with AFP serum levels,

and the suggested interval period ranges from 6 to 12 months.

A recently published review regarding screening practice disclosed the reasons

for considering HCC a good candidate for SP.[6] First, the disease must be

common (HCC is the fifth neoplasm in the world), with substantial morbidity and

mortality, and the target population must be identifiable (at present, HCC is

the first cause of death in patients with cirrhosis and the annual incidence

ranges from 1 to 4%).[2-4] The surveillance test must have low morbidity, high

sensitivity and specificity, the test must be acceptable for the target

population and the surveillance intervals must be known. Both US and serum

levels of AFP are relatively easy to perform and especially US has a high

sensitivity (71-78%) and specificity (93%) and the optimal interval is 6-12

months.[1] Currently, there is not enough information to recommend a reduction

in this interval for patients at a higher risk of HCC or for using CT scanning

as a screening test. There must be a standardized plan for subsequent evaluation

of patients found to have a new lesion in the liver detected by US surveillance.

An algorithm for investigation of a nodule in this situation was proposed in the

EASL conference and modified in the recent AASLD practice guidelines, although

none of them have been evaluated prospectively. Moreover, there is an acceptable

and effective therapy (surgery, liver transplant and percutaneous therapy),

especially if the diagnosis is made at an early stage. Unfortunately, only a

minority of patients diagnosed with HCC have tumours amenable to performing a

potentially curative therapy.

Many unresolved questions in SP for the diagnosis of HCC remain, especially

regarding the real impact of early detection on survival of the best target

population.[7-11] The aim of this study has been to compare the clinical

characteristics and survival of patients with HCC being diagnosed or not in SP

in order to establish a more accurate profile of the best target population and

to evaluate the usefulness of these programmes in terms of survival in clinical

practice.

_________________________________________________________________

With Windows Live for mobile, your contacts travel with you.

http://www.windowslive.com/mobile/overview.html?ocid=TXT_TAGLM_WL_mobile_072008