Hepatocellular carcinoma: is surveillance cost effective?

Abstract

he development of hepatocellular carcinoma (HCC) constitutes a frequent event during the evolution of patients with liver cirrhosis (3–5% annual incidence rate) and constitutes their main cause of death.1 Survival is related to tumour stage at diagnosis and to the degree of impairment of liver function. Recent data have shown thatsurvival after diagnosis is not as poor as reported years ago.2 This is due both to advances in diagnosis even in the absence of effective treatment (lead time bias) and to the application of curative treatments (surgical resection, liver transplantation, and percutaneous ablation).2 These offer the only chance of cure but their applicability and long term success with five year survival exceeding 50% require the detection of HCC at an early stage, including patients with solitary nodules ⩽5 cm or up to three nodules each ⩽3 cm.2-5 In contrast, large/multifocal tumours are less likely to benefit from curative approaches and here three year survival falls below 50% regardless of treatment.2 The need for detection of HCC at an early stage has prompted surveillance programmes for patients with cirrhosis. HCC has most requisites for such a policy6: the population at risk is known, the disease is highly prevalent, it has a high mortality, and effective screening tests are available and acceptable. However, other conditions are not yet met: the recall policy on raising suspicion is not well defined and, unfortunately, there is no unequivocal proof that treatment improves survival. Radical therapies have never been evaluated in randomised controlled trials but are widely considered “effective” and assumed to improve survival.3-5 In contrast, randomised controlled trials assessing palliative treatments (that is, chemoembolisation) have shown negative results.2Accordingly, the usefulness of surveillance programmes in cirrhotics is still controversial, leading to the suggestion that they provide a minor benefit in terms of efficacy (years of life saved) and cost effectiveness. The only method to clarify this issue would be to design a randomised controlled trial comparing surveillance versus non-surveillance in a large series of cirrhotics who would be treated if diagnosed with HCC. Such an investigation would be ethically questionable and in addition, almost unfeasible. Ultrasound examination is commonly used for evaluation of cirrhotics, irrespective of the type of symptoms and this would “contaminate” the control arm.