EDITORIAL
Opportunities to improve surveillance for hepatocellular carcinoma in the UK Individuals with cirrhosis are at greatly increased risk of death from both liver failure and hepatocellular carcinoma (HCC). In this context, many specialist societies recommend using ultrasound surveillance to detect HCC early with the aim to reduce mortality from liver disease and not only from HCC.1 2 This is a laudable aim but the studies defining the efficacy of surveillance are generally of low quality and there is no readily applicable randomised controlled trial of surveillance in a western population. Recent evidence syntheses are conflicting and while meta-analysis of non-randomised case–control studies suggests benefits of surveillance this cannot be applied to patients with cirrhosis in general.3 4 The study from Cross and coworkers in this issue of Frontline Gastroenterology used an online questionnaire to examine the provision for HCC surveillance in acute hospital NHS Trusts across the UK.5 The vast majority of respondents indicated that their Trust provided a surveillance programme for HCC. In the majority of cases however it is done on an ad hoc basis without automatic recall strategies or indeed regular 6-monthly imaging in as many as 40% of cases. It is apparent that in many centres surveillance is being done in ways that are likely to substantially reduce its effectiveness. In addition, there will inevitably be responder bias in the survey and the results reported are likely to be more favourable than the overall provision on the ground. The authors conclude that the provision of surveillance is poor and the UK is not alone in that respect.6–8 The question then is why surveillance is not done, or done poorly, in many centres. 78
The questionnaire attempted to determine possible barriers to the provision of effective surveillance and several themes were identified: cost, difficulty accessing radiology services, and ‘doubts over effectiveness’. While several studies have indicated that surveillance is likely to be cost-effective9 10 there are a number of recent developments including the introduction of sorafenib treatment that are not considered and that may have significant effects on the cost-effectiveness estimates. The issues of access to radiology services and perceived effectiveness of surveillance ultimately are due to the lack of high quality evidence supporting surveillance derived from randomised controlled trials. The view of the Royal College of Radiology is that the evidence to support surveillance is lacking and any decisions regarding surveillance and the funding for this need to be made at a local level.11 They also state that patients should be counselled as to the limitations of ultrasound and the risks of false positive and false negative examinations. These data are not readily available and according to the survey from Cross and coworkers 30% of patients receive neither written nor oral information regarding the rationale for surveillance, much less detailed information about the sensitivity and specificity of ultrasound to detect small HCC. The information required for patients considering the benefits and harms of surveillance and for those clinicians doubting its effectiveness would best come from a well-designed randomised clinical trial. There are many arguments against such a study12 and for one to be done successfully it would require engagement from all stakeholders. At present surveillance is done poorly and is likely ineffective at a population level. If such a randomised trial were to start those patients allocated to receive surveillance would do so with appropriate consent, with scans done by sonographers and radiologists with
expertise in liver disease and the diagnosis of HCC, and with appropriate recall strategies in place so that any benefits of surveillance were accurately determined. That this would in all probability substantially increase the number of patients receiving effective surveillance provides the most compelling argument of all to initiate a trial of surveillance for HCC in the UK. Ian A Rowe Correspondence to Dr Ian A Rowe, University Academic Fellow and Honorary Consultant Hepatologist, Leeds Institute for Data Analytics, Room 6.12, Level 6, Clinical Sciences Building, University of Leeds, St James’s Hospital, Leeds LS9 7TF, UK; [email protected]
Competing interests None declared. Provenance and peer review Commissioned; internally peer reviewed.
To cite Rowe IA. Frontline Gastroenterology 2016;7:78–79. Received 10 December 2015 Accepted 10 December 2015 Published Online First 8 January 2016
▸ http://dx.doi.org/10.1136/flgastro-2015-100617
REFERENCES 1 EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 2012;56:908–43. 2 Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology 2011;53:1020–2. 3 Kansagara D, Papak J, Pasha AS, et al. Screening for hepatocellular carcinoma in chronic liver disease: a systematic review. Ann Intern Med 2014;161: 261–9. 4 Singal AG, Pillai A, Tiro J. Early detection, curative treatment, and survival rates for hepatocellular carcinoma surveillance in patients with cirrhosis: a meta-analysis. PLoS Med 2014;11:e1001624. 5 Cross TJ, Villanueva A, Shetty S, et al. A national survey of the provision of ultrasound surveillance for the detection of hepatocellular carcinoma. Frontline Gastroenterol 2016;7:82–9.
Frontline Gastroenterology 2016;7:78–79. doi:10.1136/flgastro-2015-100675
EDITORIAL 6 Davila JA, Morgan RO, Richardson PA, et al. Use of surveillance for hepatocellular carcinoma among patients with cirrhosis in the United States. Hepatology 2010;52:132–41. 7 Davila JA, Henderson L, Kramer JR, et al. Utilization of surveillance for hepatocellular carcinoma among hepatitis C virus-infected veterans in the United States. Ann Intern Med 2011;154:85–93. 8 Singal AG, Yopp A, S Skinner C, et al. Utilization of hepatocellular carcinoma
surveillance among American patients: a systematic review. J Gen Intern Med 2012;27:861–7. 9 Andersson KL, Salomon JA, Goldie SJ, et al. Cost effectiveness of alternative surveillance strategies for hepatocellular carcinoma in patients with cirrhosis. Clin Gastroenterol Hepatol 2008;6:1418–24. 10 Thompson Coon J, Rogers G, Hewson P, et al. Surveillance of cirrhosis for hepatocellular carcinoma: a cost-utility analysis. Br J Cancer 2008;98:1166–75.
Frontline Gastroenterology 2016;7:78–79. doi:10.1136/flgastro-2015-100675
11 Royal College of Radiology. RCR position statement on hepatoma screening. 2014. https://www.rcr.ac.uk/ rcr-position-statement-hepatomascreening (accessed 2 Dec 2015). 12 Sherman M, Bruix J, Porayko M, et al. Screening for hepatocellular carcinoma: the rationale for the American Association for the Study of Liver Diseases recommendations. Hepatology 2012;56:793–6.
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Opportunities to improve surveillance for hepatocellular carcinoma in the UK Individuals with cirrhosis are at greatly increased risk of death from both liver failure and hepatocellular carcinoma (HCC). In this context, many specialist societies recommend using ultrasound surveillance to detect HCC early with the aim to reduce mortality from liver disease and not only from HCC.1 2 This is a laudable aim but the studies defining the efficacy of surveillance are generally of low quality and there is no readily applicable randomised controlled trial of surveillance in a western population. Recent evidence syntheses are conflicting and while meta-analysis of non-randomised case–control studies suggests benefits of surveillance this cannot be applied to patients with cirrhosis in general.3 4 The study from Cross and coworkers in this issue of Frontline Gastroenterology used an online questionnaire to examine the provision for HCC surveillance in acute hospital NHS Trusts across the UK.5 The vast majority of respondents indicated that their Trust provided a surveillance programme for HCC. In the majority of cases however it is done on an ad hoc basis without automatic recall strategies or indeed regular 6-monthly imaging in as many as 40% of cases. It is apparent that in many centres surveillance is being done in ways that are likely to substantially reduce its effectiveness. In addition, there will inevitably be responder bias in the survey and the results reported are likely to be more favourable than the overall provision on the ground. The authors conclude that the provision of surveillance is poor and the UK is not alone in that respect.6–8 The question then is why surveillance is not done, or done poorly, in many centres. 78
The questionnaire attempted to determine possible barriers to the provision of effective surveillance and several themes were identified: cost, difficulty accessing radiology services, and ‘doubts over effectiveness’. While several studies have indicated that surveillance is likely to be cost-effective9 10 there are a number of recent developments including the introduction of sorafenib treatment that are not considered and that may have significant effects on the cost-effectiveness estimates. The issues of access to radiology services and perceived effectiveness of surveillance ultimately are due to the lack of high quality evidence supporting surveillance derived from randomised controlled trials. The view of the Royal College of Radiology is that the evidence to support surveillance is lacking and any decisions regarding surveillance and the funding for this need to be made at a local level.11 They also state that patients should be counselled as to the limitations of ultrasound and the risks of false positive and false negative examinations. These data are not readily available and according to the survey from Cross and coworkers 30% of patients receive neither written nor oral information regarding the rationale for surveillance, much less detailed information about the sensitivity and specificity of ultrasound to detect small HCC. The information required for patients considering the benefits and harms of surveillance and for those clinicians doubting its effectiveness would best come from a well-designed randomised clinical trial. There are many arguments against such a study12 and for one to be done successfully it would require engagement from all stakeholders. At present surveillance is done poorly and is likely ineffective at a population level. If such a randomised trial were to start those patients allocated to receive surveillance would do so with appropriate consent, with scans done by sonographers and radiologists with
expertise in liver disease and the diagnosis of HCC, and with appropriate recall strategies in place so that any benefits of surveillance were accurately determined. That this would in all probability substantially increase the number of patients receiving effective surveillance provides the most compelling argument of all to initiate a trial of surveillance for HCC in the UK. Ian A Rowe Correspondence to Dr Ian A Rowe, University Academic Fellow and Honorary Consultant Hepatologist, Leeds Institute for Data Analytics, Room 6.12, Level 6, Clinical Sciences Building, University of Leeds, St James’s Hospital, Leeds LS9 7TF, UK; [email protected]
Competing interests None declared. Provenance and peer review Commissioned; internally peer reviewed.
To cite Rowe IA. Frontline Gastroenterology 2016;7:78–79. Received 10 December 2015 Accepted 10 December 2015 Published Online First 8 January 2016
▸ http://dx.doi.org/10.1136/flgastro-2015-100617
REFERENCES 1 EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 2012;56:908–43. 2 Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology 2011;53:1020–2. 3 Kansagara D, Papak J, Pasha AS, et al. Screening for hepatocellular carcinoma in chronic liver disease: a systematic review. Ann Intern Med 2014;161: 261–9. 4 Singal AG, Pillai A, Tiro J. Early detection, curative treatment, and survival rates for hepatocellular carcinoma surveillance in patients with cirrhosis: a meta-analysis. PLoS Med 2014;11:e1001624. 5 Cross TJ, Villanueva A, Shetty S, et al. A national survey of the provision of ultrasound surveillance for the detection of hepatocellular carcinoma. Frontline Gastroenterol 2016;7:82–9.
Frontline Gastroenterology 2016;7:78–79. doi:10.1136/flgastro-2015-100675
EDITORIAL 6 Davila JA, Morgan RO, Richardson PA, et al. Use of surveillance for hepatocellular carcinoma among patients with cirrhosis in the United States. Hepatology 2010;52:132–41. 7 Davila JA, Henderson L, Kramer JR, et al. Utilization of surveillance for hepatocellular carcinoma among hepatitis C virus-infected veterans in the United States. Ann Intern Med 2011;154:85–93. 8 Singal AG, Yopp A, S Skinner C, et al. Utilization of hepatocellular carcinoma
surveillance among American patients: a systematic review. J Gen Intern Med 2012;27:861–7. 9 Andersson KL, Salomon JA, Goldie SJ, et al. Cost effectiveness of alternative surveillance strategies for hepatocellular carcinoma in patients with cirrhosis. Clin Gastroenterol Hepatol 2008;6:1418–24. 10 Thompson Coon J, Rogers G, Hewson P, et al. Surveillance of cirrhosis for hepatocellular carcinoma: a cost-utility analysis. Br J Cancer 2008;98:1166–75.
Frontline Gastroenterology 2016;7:78–79. doi:10.1136/flgastro-2015-100675
11 Royal College of Radiology. RCR position statement on hepatoma screening. 2014. https://www.rcr.ac.uk/ rcr-position-statement-hepatomascreening (accessed 2 Dec 2015). 12 Sherman M, Bruix J, Porayko M, et al. Screening for hepatocellular carcinoma: the rationale for the American Association for the Study of Liver Diseases recommendations. Hepatology 2012;56:793–6.
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