Regular Surveillance for Hepatocellular Carcinoma Improves Survival

Katherine Kahn, DVM

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.

Related Links
Conference Coverage
World Transplant Congress 2006
http://www.medscape.com/viewarticle/542002

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