Overdiagnosis of hepatocellular carcinoma: Prevented by guidelines?

Rich, Nicole E.

doi:10.1002/hep.32284

Cited by 36 publications

(36 citation statements)

References 149 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“… 40 Furthermore, there is a dearth of data on contemporary populations of patients, such as those with nonalcohol-related fatty liver disease and post–sustained virologic response cirrhosis, in whom indolent growth patterns may be more likely and there are higher competing risks of noncancer mortality, potentially increasing chances of overdiagnosis. 41 , 42 , 43 Despite these imperfect data, several studies have demonstrated a favorable risk-benefit ratio of HCC surveillance, and modeling studies have suggested the practice is likely cost-effective. 43 , 44 …”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Barriers to Surveillance for Hepatocellular Carcinoma in a Multicenter Cohort

et al. 2022

Self Cite

View full text Add to dashboard Cite

IMPORTANCEHepatocellular carcinoma (HCC) surveillance is underused in clinical practice, which may be owing to patient and clinician barriers. OBJECTIVE To characterize HCC surveillance barriers and associations with clinical outcomes in a multicenter cohort of patients with cirrhosis. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included 5 medical centers in the United States. Patients with cirrhosis and newly diagnosed HCC treated from 2014 to 2018 were included. Data were analyzed from June 2021 to February 2022. EXPOSURE Surveillance completion in the 36-month period prior to HCC diagnosis. MAIN OUTCOMES AND MEASURES Surveillance receipt was classified as semiannual, annual, or no surveillance. Multivariable logistic regression analysis was used to identify factors associated with semiannual surveillance. We conducted multivariable logistic and Cox regression analyses to characterize associations between surveillance completion with curative treatment and overall survival. RESULTS A total 629 eligible patients (median [IQR] age, 63.6 [56.2-71.0] years; 491 [78.1%] men) were assessed, including 7 American Indian or Alaska Native patients (1.1%), 14 Asian patients (2.2), 176 Black patients (28.0%), 86 Hispanic patients (13.1%), and 340 White patients (54.1%). Nearly two-thirds of the cohort had no surveillance prior to HCC diagnosis (mean [range by site] 63.7%[37.9%-80.4%]), with a mean (range by site) of 14.0% (5.3%-33.3%) of patients having received semiannual surveillance and 22.3% (14.3%-28.8%) of patients having received annual surveillance.The most common reasons for no surveillance were lack of surveillance orders or nonadherence (mean [range by site], 82.4% [66.7%-92.4%], although a mean (range by site) of 17.6% (10.2%-22.1%) of patients had unrecognized cirrhosis at HCC presentation. Semiannual surveillance was associated with hepatitis B infection (odds ratio [OR], 3.06 [95% CI, 1.24-7.23]) and inversely associated with Black race (OR, 0.41 [95% CI, 0.20-0.80]) and lack of cirrhosis recognition (OR, 0.14 [95% CI, 0.02-0.46]). Semiannual HCC surveillance was significantly associated with curative treatment receipt (OR, 2.73 [95% CI, 1.60-4.70]) but not overall survival (HR, 0.81 [95% CI, 0.55-1.18]). CONCLUSIONS AND RELEVANCEIn this cohort study of patients with cirrhosis, HCC surveillance was underused in more than 80% of patients and associated with failures across the screening process. Dedicated programs to improve cirrhosis detection and HCC surveillance attainment are needed.

show abstract

Section: Discussionmentioning

confidence: 99%

“… 41 , 42 , 43 Despite these imperfect data, several studies have demonstrated a favorable risk-benefit ratio of HCC surveillance, and modeling studies have suggested the practice is likely cost-effective. 43 , 44 …”

Section: Discussionmentioning

confidence: 99%

Barriers to Surveillance for Hepatocellular Carcinoma in a Multicenter Cohort

et al. 2022

Self Cite

View full text Add to dashboard Cite

show abstract

“…To the best of our knowledge, our study is one of the first to show that visualisation limitations were also associated with higher odds of false‐positive ultrasound results. Notably, false‐positive results can result in physical, financial and psychological screening‐related harms and thereby decrease the overall value of surveillance programmes 10,21,22 . These data are particularly concerning given that poor visualisation is more likely to occur in patients with obesity and non‐viral aetiologies of cirrhosis, which are increasingly common populations undergoing HCC surveillance 23,24 .…”

Section: Discussionmentioning

confidence: 99%

“…Notably, false-positive results can result in physical, financial and psychological screening-related harms and thereby decrease the overall value of surveillance programmes. 10,21,22 These data are particularly concerning given that poor visualisation is more likely to occur in patients with obesity and non-viral aetiologies of cirrhosis, which are increasingly common populations undergoing HCC surveillance. 23,24 Our findings suggest that while moderate visualisation limitations (Vis score B) may impair the differentiation of benign observations (eg, dysplastic nodules, heterogeneous parenchyma) from malignant lesions, the examination quality may be sufficiently adequate for detecting true HCC nodules.…”

Section: Discussionmentioning

confidence: 99%

Association between ultrasound quality and test performance for HCC surveillance in patients with cirrhosis: a retrospective cohort study

Chong

Schoenberger

Yekkaluri

et al. 2022

Aliment Pharmacol Ther

Self Cite

View full text Add to dashboard Cite

Background: Ultrasound visualisation is limited in approximately 20% of patients with cirrhosis undergoing hepatocellular carcinoma (HCC) surveillance; however, it is unknown if impaired visualisation directly impacts test performance. We aimed to evaluate the association between ultrasound visualisation and surveillance test performance. Methods:We performed a retrospective cohort study among patients with cirrhosis, with or without HCC, who underwent ultrasound-based surveillance at two large health systems between July 2016 and July 2019. Ultrasound visualisation assessment was recorded by interpreting radiologists using the ultrasound LI-RADS Visualisation score. We performed logistic regression analyses to evaluate the association between ultrasound visualisation and diagnostic test performance. We assessed sensitivity for HCC detection among ultrasounds performed in the year prior to HCC diagnoses and specificity using ultrasounds in those without HCC.Results: Among 186 patients with HCC, severely limited visualisation (Vis Score C) on ultrasound prior to HCC diagnosis was associated with increased odds of falsenegative results, that is lower sensitivity (OR 7.94, in multivariable analysis. Ultrasound sensitivity with visualisation scores A or B exceeded 75%, compared to only 27.3% with visualisation score C. Among 2052 cirrhosis patients without HCC, moderate visualisation limitations (Vis score B) were associated with increased odds of false-positive results (OR 1.60, 1.13-2.27), although specificity exceeded 95% across all visualisation scores. Conclusions: Impaired ultrasound visualisation is associated with worse surveillance test performance. Alternative blood-based biomarkers and imaging strategies are needed for patients at risk for ultrasound-based surveillance failure.

show abstract

“…Finally, screening for HCC in our cohort of cirrhosis SVR patients will have been much higher than in the GP. This could have led to an ascertainment bias, particularly if there is a potential for HCC deaths to be misattributed to other causes or if HCC overdiagnosis (34) exists in cirrhosis SVR patients. This issue is not well understood but could potentially have led us to overstate the difference in HCC incidence between our cohort and the GP.…”

Section: Discussionmentioning

confidence: 99%

Comparing Predicted Probability of Hepatocellular Carcinoma in Patients With Cirrhosis With the General Population: An Opportunity to Improve Risk Communication?

et al. 2022

View full text Add to dashboard Cite

INTRODUCTION:Risk scores estimating a patient's probability of a hepatocellular carcinoma (HCC) diagnosis are abundant but are difficult to interpret in isolation. We compared the predicted HCC probability for individuals with cirrhosis and cured hepatitis C with the general population (GP).METHODS:All patients with cirrhosis achieving sustained viral response (SVR) in Scotland by April 2018 were included (N = 1,803). The predicted 3-year probability of HCC at time of SVR achievement was determined using the aMAP prognostic model. GP data on the total number of incident HCCs in Scotland, stratified by demographics, were obtained from Public Health Scotland. Predicted HCC risk of cirrhosis SVR patients was compared with GP incidence using 2 metrics: (i) incidence ratio: i.e., 3-year predicted probability for a given patient divided by the 3-year probability in GP for the equivalent demographic group and (ii) absolute risk difference: the 3-year predicted probability minus the 3-year probability in the GP.RESULTS:The mean predicted 3-year HCC probability among cirrhosis SVR patients was 3.64% (range: 0.012%–36.12%). Conversely, the 3-year HCC probability in the GP was much lower, ranging from <0.0001% to 0.25% depending on demographics. The mean incidence ratio was 410, ranging from 5 to >10,000. The mean absolute risk difference was 3.61%, ranging from 0.012% to 35.9%. An online HCC-GP comparison calculator for use by patients/clinicians is available at https://thrive-svr.shinyapps.io/RShiny/.DISCUSSION:Comparing a patient's predicted HCC probability with the GP is feasible and may help clinicians communicate risk information and encourage screening uptake.

show abstract

Overdiagnosis of hepatocellular carcinoma: Prevented by guidelines?

Cited by 36 publications

References 149 publications

Barriers to Surveillance for Hepatocellular Carcinoma in a Multicenter Cohort

Barriers to Surveillance for Hepatocellular Carcinoma in a Multicenter Cohort

Association between ultrasound quality and test performance for HCC surveillance in patients with cirrhosis: a retrospective cohort study

Comparing Predicted Probability of Hepatocellular Carcinoma in Patients With Cirrhosis With the General Population: An Opportunity to Improve Risk Communication?

Contact Info

Product

Resources

About