HCC screening linked to reduced mortality but remains ‘underused in clinical practice’
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Key takeaways:
- Hepatocellular carcinoma was detected with screening in 42.3% vs. 57.7% without screening.
- Screen detection was associated with improved early-stage detection and reduced mortality.
Hepatocellular carcinoma screening in at-risk patients was linked to reduced mortality after accounting for lead-time and length-time biases, as well as improved early tumor detection and treatment, according to data in JAMA Network Open.
“Although there have been several studies examining the value of HCC screening in patients with cirrhosis, there continues to be debate if this is beneficial,” Amit G. Singal, MD, MS, medical director of the liver tumor program and chief of hepatology at UT Southwestern Medical Center, told Healio. “Indeed, hepatology professional society guidelines recommend screening, but this has not yet been adopted by larger societies. This discrepancy is partly due to the lack of randomized data and the practice only being supported by cohort studies that have inherent limitations including lead time bias, length time bias and residual confounding.”
Singal continued: “While some prior studies have adjusted for lead-time bias, there are fewer that have adjusted for length-time bias, so we conducted a study to characterize the potential clinical benefits of HCC screening after adjusting for lead-time and length-time bias.
In a retrospective cohort study, Singal and colleagues enrolled 1,313 patients (mean age, 61.7 years; 75.6% men) with a new diagnosis of HCC between January 2008 and December 2022, including patients with cirrhosis or noncirrhotic chronic hepatitis B virus infection. More than half of patients had Barcelona Clinical Liver Cancer stage O/A disease (56.3%) and almost two-thirds (62.5%) had Child-Pugh class A cirrhosis at baseline.
The primary outcome was screen-detected HCC, defined by abnormal screen-intent abdominal imaging or alpha-fetoprotein level within 6 months prior to diagnosis.
According to results, HCC was detected with screening in 42.3% of patients and detected without screening in 57.7% of patients. More patients with screen-detected HCC had early-stage disease compared with those with non-screen-detected HCC (70.7% vs. 45.7%; RR = 1.54; 95% CI, 1.41-1.7) as well as curative treatment (51.5% vs. 33.5%; RR = 1.52; 95% CI, 1.34-1.74).
“We continue to find that screening is underused in clinical practice with only 42% of HCC cases detected by screening,” Singal said. “HCC screening was associated with improved early tumor detection and increased curative treatment receipt in adjusted models.”
Although both groups demonstrated similar tumor doubling times (median, 3.8 vs. 5.6 months) and proportion of indolent tumors (35.4% vs. 38.1%; RR = 0.93; 95% CI, 0.6-1.43), median survival was significantly higher with screen detection (37 months [95% CI, 30.9-47.9] vs. 19 months [95% CI, 16.9-21.9]).
Multivariable analysis demonstrated that screen detection was significantly associated with reduced mortality (HR = 0.65; 95% CI, 0.56-0.75) even after adjusting for curative treatment (HR = 0.75; 95% CI, 0.65-0.87). Median survival dropped to 31.4 months in the screen-detected group after adjusting for lead-time bias, with decreased survival estimates persisting after adjusting for length-time bias. However, 3- and 5-year survival remained longer among those with screen-detected HCC vs. those without.
“These data not only highlight the likely benefits of HCC screening but also reinforce the importance of adjusting for these biases of cohort studies in future studies,” Singal told Healio. “Although the data for HCC screening remains imperfect, our study highlights its likely benefit in patients with cirrhosis.”
He continued: “Given the availability of curative therapies for patients detected with early-stage HCC, it is important that we maximize efforts for early HCC detection in clinical practice.”
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