- Email: [email protected]
Screening for Hepatocellular Carcinoma in Patients with Cirrhosis: A Need to Increase Awareness
Accepted Manuscript Screening for Hepatocellular Carcinoma in Patients with Cirrhosis: A Need to Increase Awareness David G. Koch, MD, MSCR PII:
S0002-9343(17)30346-7
DOI:
10.1016/j.amjmed.2017.03.021
Reference:
AJM 14010
To appear in:
The American Journal of Medicine
Received Date: 16 March 2017 Accepted Date: 16 March 2017
Please cite this article as: Koch DG, Screening for Hepatocellular Carcinoma in Patients with Cirrhosis: A Need to Increase Awareness, The American Journal of Medicine (2017), doi: 10.1016/ j.amjmed.2017.03.021. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Screening for Hepatocellular Carcinoma in Patients with Cirrhosis: A Need to Increase Awareness
RI PT
David G. Koch MD, MSCR1 Department of Internal Medicine, Division of Gastroenterology and Hepatology1
EP
Correspondence:
TE D
M AN U
SC
Medical University of South Carolina, Charleston
AC C
David Koch, MD, MSCR MUSC Division of Gastroenterology and Hepatology Department of Medicine Suite 249, MSC 290 114 Doughty Street Charleston, SC 29425 email: [email protected] Conflict of Interest: None Financial Disclosures: None
ACCEPTED MANUSCRIPT
Hepatocellular carcinoma (HCC) is the most common primary liver cancer, occurring largely in patients with cirrhosis. The incidence of hepatocellular carcinoma is rising in the United States as is its mortality, making hepatocellular carcinoma one of the
RI PT
leading causes of cancer-related deaths in the country1. Despite the fact that early detection improves survival in patients with hepatocellular carcinoma, biannual
screening with ultrasonography has not been widely adopted by physicians in the
SC
United States2-3. This is likely due to the limited amount of data from the United States demonstrating its benefit.
M AN U
In this issue, Singal et al., provide much needed “real world” data to support the notion that screening for hepatocellular carcinoma in patients with cirrhosis is indeed advantageous. By retrospectively analyzing data from 374 patients diagnosed with hepatocellular carcinoma in four United States health systems, they were able to show
TE D
that patients with hepatocellular carcinoma detected by screening had an earlier tumor stage at the time of diagnosis as well as improved survival when compared to patients with hepatocellular carcinoma that was detected incidentally or symptomatically.
EP
Screened patients were also more likely to receive curative treatments for their hepatocellular carcinoma that included local ablative therapy, surgical resection, or
AC C
transplantation.
While these results are compelling, the authors report other data that we should
recognize since they identify potential deficiencies in our current management practices. Of the hepatocellular carcinoma cases included in the study, only a minority (42%) were actually detected by screening. Also, the majority of the patients had not received specialty care from a hepatologist in the year prior to diagnosis, a factor that
ACCEPTED MANUSCRIPT
significantly increased the likelihood that hepatocellular carcinoma was detected by screening. Most concerning, however, is the fact that only a small proportion of hepatocellular carcinoma patients (20%) received a potentially curative therapy,
RI PT
including just 34.6% of those with early stage disease. This suggests that the majority of patients with cirrhosis are not receiving the health care measures that would likely improve their survival by detecting hepatocellular carcinoma at an early stage and by
SC
providing curative therapies once hepatocellular carcinoma is recognized. So, how do we change the current culture so that providing the appropriate screening tests and
M AN U
curative therapies in this patient population is associated with quality care? Firstly, we must increase awareness among physicians that hepatocellular carcinoma screening in is indeed beneficial for patients with cirrhosis. Until a reliable blood test is developed that is able to detect hepatocellular carcinoma (a task that
TE D
alphafetoprotein alone fails to provide), biannual ultrasound appears to be our best option. Also, the role of the hepatologist in managing patients with cirrhosis must be addressed. As was identified in this study, patients with hepatocellular carcinoma that
EP
received hepatology subspecialty care in the year prior to diagnosis were far more likely to have been detected by screening than were those without hepatology care (80% vs.
AC C
20%, respectively). However, in the United States, primary care physicians provide the greatest amount of care for patients with cirrhosis, as only 20-40% of cirrhotic patients are managed by a hepatology-trained subspecialist4. It is also not conceivable that hepatologists will be able to take on the entirety of the care for all patients with cirrhosis, given the rising burden of chronic liver disease. Instead, there must be a coordinated approach between primary care physicians and hepatologists in order to optimize
ACCEPTED MANUSCRIPT
screening in this population. However, no measure of collaboration will ultimately prove to be beneficial if the appropriate treatments are not provided for early stage tumors that
be done. References
RI PT
screening would hopefully detect. Clearly, there is still much more work that needs to
1. Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM.
SC
Projecting cancer incidence and deaths to 2030: the unexpected burden of
2014;74:2913-2921.
M AN U
thyroid, liver, and pancreas cancers in the United States. Cancer Res
2. Singal AG, Yopp A, Skinner CS, Packer M, Lee WM, Tiro JA. Utilization of hepatocellular carcinoma surveillance among American patients: a systematic review. J Gen Intern Med 2012;27:861-867.
TE D
3. Singal AG, Li X, Tiro J, Kandunoori P, Adams-Huet B, Nehra M, Yopp A. Racial, Social and Clinical Determinants of Hepatocellular Carcinoma Surveillance. Am J Med 2014.
EP
4. Sanyal A, Poklepovic A, Moyneur E, Barghout V. Population-based risk factors and resource utilization for HCC: US perspective. Curr Med Res Opin. 2010;
AC C
26:2183–2191.
S0002-9343(17)30346-7
DOI:
10.1016/j.amjmed.2017.03.021
Reference:
AJM 14010
To appear in:
The American Journal of Medicine
Received Date: 16 March 2017 Accepted Date: 16 March 2017
Please cite this article as: Koch DG, Screening for Hepatocellular Carcinoma in Patients with Cirrhosis: A Need to Increase Awareness, The American Journal of Medicine (2017), doi: 10.1016/ j.amjmed.2017.03.021. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Screening for Hepatocellular Carcinoma in Patients with Cirrhosis: A Need to Increase Awareness
RI PT
David G. Koch MD, MSCR1 Department of Internal Medicine, Division of Gastroenterology and Hepatology1
EP
Correspondence:
TE D
M AN U
SC
Medical University of South Carolina, Charleston
AC C
David Koch, MD, MSCR MUSC Division of Gastroenterology and Hepatology Department of Medicine Suite 249, MSC 290 114 Doughty Street Charleston, SC 29425 email: [email protected] Conflict of Interest: None Financial Disclosures: None
ACCEPTED MANUSCRIPT
Hepatocellular carcinoma (HCC) is the most common primary liver cancer, occurring largely in patients with cirrhosis. The incidence of hepatocellular carcinoma is rising in the United States as is its mortality, making hepatocellular carcinoma one of the
RI PT
leading causes of cancer-related deaths in the country1. Despite the fact that early detection improves survival in patients with hepatocellular carcinoma, biannual
screening with ultrasonography has not been widely adopted by physicians in the
SC
United States2-3. This is likely due to the limited amount of data from the United States demonstrating its benefit.
M AN U
In this issue, Singal et al., provide much needed “real world” data to support the notion that screening for hepatocellular carcinoma in patients with cirrhosis is indeed advantageous. By retrospectively analyzing data from 374 patients diagnosed with hepatocellular carcinoma in four United States health systems, they were able to show
TE D
that patients with hepatocellular carcinoma detected by screening had an earlier tumor stage at the time of diagnosis as well as improved survival when compared to patients with hepatocellular carcinoma that was detected incidentally or symptomatically.
EP
Screened patients were also more likely to receive curative treatments for their hepatocellular carcinoma that included local ablative therapy, surgical resection, or
AC C
transplantation.
While these results are compelling, the authors report other data that we should
recognize since they identify potential deficiencies in our current management practices. Of the hepatocellular carcinoma cases included in the study, only a minority (42%) were actually detected by screening. Also, the majority of the patients had not received specialty care from a hepatologist in the year prior to diagnosis, a factor that
ACCEPTED MANUSCRIPT
significantly increased the likelihood that hepatocellular carcinoma was detected by screening. Most concerning, however, is the fact that only a small proportion of hepatocellular carcinoma patients (20%) received a potentially curative therapy,
RI PT
including just 34.6% of those with early stage disease. This suggests that the majority of patients with cirrhosis are not receiving the health care measures that would likely improve their survival by detecting hepatocellular carcinoma at an early stage and by
SC
providing curative therapies once hepatocellular carcinoma is recognized. So, how do we change the current culture so that providing the appropriate screening tests and
M AN U
curative therapies in this patient population is associated with quality care? Firstly, we must increase awareness among physicians that hepatocellular carcinoma screening in is indeed beneficial for patients with cirrhosis. Until a reliable blood test is developed that is able to detect hepatocellular carcinoma (a task that
TE D
alphafetoprotein alone fails to provide), biannual ultrasound appears to be our best option. Also, the role of the hepatologist in managing patients with cirrhosis must be addressed. As was identified in this study, patients with hepatocellular carcinoma that
EP
received hepatology subspecialty care in the year prior to diagnosis were far more likely to have been detected by screening than were those without hepatology care (80% vs.
AC C
20%, respectively). However, in the United States, primary care physicians provide the greatest amount of care for patients with cirrhosis, as only 20-40% of cirrhotic patients are managed by a hepatology-trained subspecialist4. It is also not conceivable that hepatologists will be able to take on the entirety of the care for all patients with cirrhosis, given the rising burden of chronic liver disease. Instead, there must be a coordinated approach between primary care physicians and hepatologists in order to optimize
ACCEPTED MANUSCRIPT
screening in this population. However, no measure of collaboration will ultimately prove to be beneficial if the appropriate treatments are not provided for early stage tumors that
be done. References
RI PT
screening would hopefully detect. Clearly, there is still much more work that needs to
1. Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM.
SC
Projecting cancer incidence and deaths to 2030: the unexpected burden of
2014;74:2913-2921.
M AN U
thyroid, liver, and pancreas cancers in the United States. Cancer Res
2. Singal AG, Yopp A, Skinner CS, Packer M, Lee WM, Tiro JA. Utilization of hepatocellular carcinoma surveillance among American patients: a systematic review. J Gen Intern Med 2012;27:861-867.
TE D
3. Singal AG, Li X, Tiro J, Kandunoori P, Adams-Huet B, Nehra M, Yopp A. Racial, Social and Clinical Determinants of Hepatocellular Carcinoma Surveillance. Am J Med 2014.
EP
4. Sanyal A, Poklepovic A, Moyneur E, Barghout V. Population-based risk factors and resource utilization for HCC: US perspective. Curr Med Res Opin. 2010;
AC C
26:2183–2191.