Mass screening for liver cancer: results from a demonstration screening project in Zhongshan City, China

Abstract

Current Chinese national guidelines recommend routine screening for liver cancer in patients positive for HBsAg, irrespective of fibrosis status, age, or family history of liver cancer. We aim to evaluate whether the recommended screening strategy could reduce liver-cancer-specific mortality. We conducted a liver cancer mass screening trial in Xiaolan Town, Zhongshan City, China, among residents aged 35–64 years in 2012. All volunteers were offered serological testing for hepatitis B virus surface antigen (HBsAg). We proposed biannual screening using serum alpha-fetoprotein (AFP) and ultrasonography examination for subjects positive for HBsAg. Among 17,966 participants (26.2% of 68,510 eligible residents) who were free of liver cancer at baseline in 2012, we identified 57 incident cases of liver cancer within the first 4 years of follow-up (i.e., 43 among 2,848 HBsAg-positive participants and 14 among 15,118 HBsAg-negative participants), compared with 104 cases identified in non-participants (N = 50,544). A total of 207 participants had the recommended number of ultrasonography examinations (every 6 months) during the screening period. Compared with cases identified from non-participants, the cases arising among participants were more likely to be at early stage and had better survival than those among non-participants. However, we did not observe a reduction in liver cancer-specific mortality rate among participants (relative risk = 1.04, 95% confidence interval = 0.68, 1.58, P = 0.856). Our demonstration screening study does not show a reduction in liver cancer mortality within the first 4 years of follow-up according to current guidance in China, although long-term efficacy remains to be evaluated. Targeted surveillance among high-risk individuals as recommended by international guidelines, along with measures to improve compliance, should be evaluated in the Chinese population.

Cancer burden of major cancers in China: A need for sustainable actions

“…In addition, simple and novel technologies for early detection are also in great need in China, such as self‐sampling for cervical cancer screening [28], although the acceptance was previously observed as being low, more emphasis should be placed on such technologies. Data from the National Cancer Registry of China (NCCRC) showed that cancer survival increased substantially for the overall combined cancers from 2003 to 2015 [29], which could be partly attributed to the implementation of mass screening, although the effectiveness of screening on liver cancer was unclear [30‐32]. Other reasons to improve cancer survival may include improvements in the health care system and New Cooperative Medical Scheme [33‐35].…”

Liver cancer screening in China: practices and its extended questions

“…This finding shows that the screening of individuals at highrisk with semiannual AFP and US detection is effective not only in increasing detection rate of early stage liver cancer but also in improving patients' survival. Ji et al [102] reported another example from Zhongshan, Guangdong Province that started in 2012.…”

“…Although there is currently no internationally recognized program for the screening for liver cancer, except for some aspects of the consensus, in the past decades China has experienced many screening trials [15,19,20,90,93,97,100,102] , which have fully demonstrated the Chinese characteristics (most patients are HBV-related liver cancer) and the need for the management and control for the one of its most common malignancies. Professional societies in Western countries had proposed recommendations and guidelines on this special issue [108] , although in the recent American Cancer Society Guidelines, the screening for liver cancer is not mentioned [133] .…”

Cancer screening in Australia: future directions in melanoma, Lynch syndrome, and liver, lung and prostate cancers

“…Another recent community-based trial among patients with positive chronic hepatitis B in China found that participation in ultrasound-based surveillance improved early tumour detection and survival but did not reduce HCC-related mortality. 44 Although a clear mortality benefit has not been demonstrated, routine HCC surveillance generally fulfils criteria for a successful screening program: there are two easily identified populations that are at high risk; the tumour usually has a long latent preclinical phase detectable with imaging, and curative treatments are feasible if diagnosed at an early stage; and surveillance with ultrasound is an acceptable, low-risk technique with an overall sensitivity of 84% for all HCCs and 47% for early HCC, as demonstrated by meta-analysis. 45 The reason surveillance has not had a clear impact on HCC mortality is complex.…”