What are the greatest challenges in the early detection of Hepatocellular Carcinoma (HCC)?

So, what are the greatest challenges in the early detection of HCC? I would say, it’s firstly identifying the patients who are at risk for HCC; and in the large, that’s the patients with cirrhosis, and at the moment we’re not detecting those patients with cirrhosis, who are the greatest population at risk. So, what do we need to do about that? Well, we need to find them; and that means empowering the GPs, particularly, to have early detection of cirrhosis, so they can enroll patients in surveillance for HCC.

What is one thing you would do to improve HCC surveillance?

If I was to improve one thing in HCC surveillance, what would that be? Well again, I think it’s that first step in identifying the patients who need surveillance. But then once you’ve done that, how do you get most patients to surveillance? Well in the Australian context, that’s going to mean having a test that’s affordable, and that’s effective, and that is applicable to patients wherever they are in Australia. So it might be that one sort of test is available to somebody who lives very close to a major tertiary hospital, but for many many people in Australia, they’re not in that situation. They’re going to be living in rural or remote Australia, in regional towns, all over the country; because the risks of liver disease are diverse, and we’ve got to have a surveillance test that is applicable to all of them.

What are the challenges for patients in maintaining HCC surveillance? How can we overcome these?

So these are patients who we know they should be having surveillance. The patients know they should be having surveillance, and their doctors know they should be having surveillance, and there are challenges yet to getting those patients in regular surveillance. And by surveillance, we mean an assessment that’s conducted every 6 months, and currently that would be an ultrasound with or without an AFP level. So the challenges those patients have is firstly, they forget, their doctors forget, they drop out of follow up. The COVID pandemic had a huge impact in people being reluctant to access care and to go to diagnostic centers for imaging, for blood tests even. And then there are patients that move. There are patients that have to pay out of pocket to access testing, so the financial barrier is huge, and particularly the community of patients who live with liver disease are often the patients who can’t afford to access non-Medicare funded investigations. So having tests that are affordable, accessible, near them that they remember to have with regular reminders, are all ways that we can overcome those challenges.

What is the optimal model of care in HCC surveillance?

So what is an optimal model of care for an HCC surveillance program? Well it might be that there is not one model for everybody; and if people are coming regularly to a major center or have access to high quality ultrasound and blood testing, then a combination of ultrasound and blood testing might be what’s suitable for them. For other patients, another model of care might be more appropriate where they don’t have regular access to ultrasound, but where a blood test that had high sensitivity and high specificity may fill that gap. So it’s going to be varied, it’s going to be dependent on what the access to medical care is, what the access to imaging and blood testing care is, what the access to, perhaps, nursing care is; dependent on where that patient is, and where they live in the country.

Quick Summary

This study aimed to compare the performance of surveillance imaging with or without alpha fetoprotein (AFP) for early detection of hepatocellular carcinoma (HCC) in patients with cirrhosis. The researchers searched MEDLINE and SCOPUS and found that ultrasound alone had low sensitivity for detecting early-stage HCC, but the addition of AFP significantly increased sensitivity. The study concluded that ultrasound plus AFP measurement is a more effective surveillance strategy for detecting HCC in clinical practice. However, only a few studies evaluated computed tomography or magnetic resonance image-based surveillance, which detected HCC with high sensitivity.

Authors: Kristina Tzartzeva, Joseph Obi, Nicole E. Rich, Neehar D. Parikh, Jorge A. Marrero, Adam Yopp, Akbar Waljee, Amit G. Singal