Hepatocellular Carcinoma Screening @ surveillance

HEPATOCELLULAR CARCINOMA SCREENING AND SURVEILLANCE:
"Detecting undiagnosed cirrhosis and monitoring quality of surveillance for hepatocellular carcinoma using stored data from the computerized patient records: a pilot study." Abstract 120-AASLD, Crocker. Surveillance for hepatocellular carcinoma is now standard of care in patients who are deemed at risk for HCC development, as per the AASLD guidelines from 2005. This study evaluated VA Medical Center electronic medical records to identify patients who were potentially at risk for developing hepatocellular carcinoma including identifying patients with hepatitis C or cirrhosis. They highlighted in the study that liver enzymes, liver enzyme pattern and platelet data would allow a computerized data-based analysis to indicate patients who potentially have cirrhosis or were at increased risk of hepatocellular carcinoma. They were able to identify over 1000 patients with a calculated fibrosis score of greater than 3, who had not yet been identified as having cirrhosis or at an increased risk of HCC, and who had not had liver imaging during the proceeding year. In over 500 patients who were diagnosed with cirrhosis in their medical chart, nearly half of these patients had not had liver imaging within the last year. This abstract provides support for the use of electronic health record surveillance to provide additional screening and follow-up surveillance to identify patients at risk of HCC. It needs to be determined as to whether this aggressive data base review would result in improved outcomes, increased number of patients cured of their liver cancer by liver transplant, and the ability to provide life-prolonging therapies such as ablative treatments or oral multi-kinase inhibitors. "Implementation of AASLD hepatocellular carcinoma practice guidelines in North America, two years of experience."Abstract 128-AASLD, Khalili. This abstract describes two years of implementation, in Toronto, of the Hepatocellular Carcinoma Screening Protocol based on the AASLD HCC practice guidelines. This abstract demonstrated data that this screening protocol led to detection of a larger number of small tumors, including, HCCs, with the median size of 1.77-cm. 22% of the "early" lesions detected in this study were hemangiomas. This screening protocol was found to be resource intense, and the authors suggested that the modified imaging strategies may help decrease the amount of resource utilization per cancer found.

RISK FACTORS FOR HEPATOCELLULAR CARCINOMA:
"Use of exogenous insulin or sulfonylureas as a potential risk factor for hepatocellular carcinoma in hepatitis C patients with diabetes mellitus." Abstract 51-IASL, Taniguchi. Insulin and insulin-like growth factors are known mediators of carcinogenesis. Patients with diabetes, metabolic syndrome and fatty liver are at increased risk for hepatocellular carcinoma especially in the setting of cirrhosis. In this abstract, the authors describe a cross-sectional and hospital-based registry in 2004 and 2007 in which 351 patients with hepatitis and 194 patients with HCC were enrolled in this study. They identified that exogenous insulin administration in combination with sulfonylureas resulted in an increased risk of hepatocellular carcinoma. Whether any of these medications actually increased the risk directly or whether hepatitis C combined with metabolic syndrome in patients who were undergoing treatment and surveillance in the fatty liver are at increased risk was not able to be gleaned from the study data. Whether insulin treatment will be considered as a primary risk factors for hepatocellular carcinoma remains to be elucidated and large prospective studies would be needed to truly answer this important question.. If indeed insulin and sulfonylureas result in an increased risk of HCC, this would provide strong support for physician advocacy of patients who have hepatitis C undergo early and aggressive weight loss and modification of their metabolic syndrome, without use of diabetes-specific treatment modalities. Further research is clearly needed in this important area. "Pattern of serial HBV DNA levels and HCC development in patients with cirrhosis."Abstract 841, Kwan. In this study, 325 patients who were diagnosed with HCC between 2005 and 2007 were evaluated. Approximately 50 patients had HBV DNA levels for greater than one year before the development of HCC. This was a double-case control study. It identified that patients with cirrhosis with consistently high HBV DNA of greater than 104 copies/mL had more than a three-fold increased risk of HCC that individuals with less than 104 copies/mL. This abstract provides further support that increased HBV DNA levels, over time, increase the risk of development of hepatocellular carcinoma. "Hepatocellular carcinoma is the main indication for a liver transplantation among HBV patients in the era of nucleoside and nucleotide analog therapies." Abstract 1437-AASLD, Hahn. With the advent of markedly improved anti-HBV therapies, fewer and fewer patients are presenting with end-stage liver disease to liver and liver transplant center. This was recently demonstrated by Dr. Kim at AASLD Boston, 2007. In this study there was further support to Dr. Kim's analysis that states that fewer and fewer patients are presenting with liver failure due to hepatitis B attributed to improved HBV control and HBV suppression, and these patients are now living long enough, as well as due to intensified and a more compliant screening and surveillance, to develop hepatocellular carcinoma. This provides support that community based screening for hepatitis B may lead to identification of patients with earlier stages of disease, and potentially earlier intervention that may improve outcomes, but this needs to be applied in combination with compliant HCC surveillance to allow intervention in those patients with HCC, which may further improve their overall survival or opportunities to undergo a liver transplantation. "Interferon therapy for hepatitis C patients curatively treated for hepatocellular carcinoma with percutaneous therapies." Abstract 1241-AASLD, Goto. Interferon has the ability to cure hepatitis C disease. In patients who have hepatitis C, advanced liver disease in hepatocellular carcinoma, one needs to consider treating hepatitis C after treatment for hepatocellular carcinoma, to potentially inhibit disease progression. In this study an important addition to this contention was demonstrated stating that patients who had hepatitis C, who were treated with interferon and had an SVR, had markedly reduced risk of recurrent HCC after that interferon treatment. With improvements in survival at three, five and seven years that were substantially better than individuals who did not have an SVR after interferon treatment, this survival benefit may relate to decreased risk of disease progression and/or recurrent HCC. "HCC in patients with hepatitis C cirrhosis and sustained virologic response with interferon and ribavirin therapy in a META-analysis."Abstract 1440, Jaganmohan. This is a study that evaluated publications from PubMed, Ovid, Cochrane, Embase and the ISI Web of Science and reviewed the treatment of patients who had chronic HCV infections and cirrhosis who underwent treatment with interferon and ribavirin. The authors performed a Meta-analysis of these studies and demonstrated the odds of HCC development in non-SVR groups was 5.1-fold higher when compared to patients who had a sustained virologic response. The author's concluded that combination therapy of interferon and ribavirin resulted in a significant reduction in the development of HCC in patients who had hepatitis C cirrhosis and who achieved SVR on treatment. This publication would provide further support for focusing on patients in ones clinical practice who have hepatitis C and advanced disease or cirrhosis and to counsel patients about the benefits of antiviral therapy that could potentially lead to decreased rates of liver cancer and thus improved patient outcome.

SCREENING AND SURVEILLANCE FOR HEPATOCELLULAR CARCINOMA:
"Liver cancer screening practices in all providers with a high prevalence of hepatitis B infected Asian patient population." Abstract 1457-AASLD, Khalili. Screening and surveillance for hepatocellular carcinoma is now the standard of care in high-risk individuals. This is the analysis in the San Francisco Safety Net System of primary and specialty providers who underwent a survey as to their screening and surveillance practices in their medical practices. Most common HCC surveillance tool was an AFP every 6 to 12 months, in combination with an ultrasound in 60% of individuals (with the ultrasound being performed every 12 months). Interestingly, transaminases in 72% of responders and an HBV viral load in 38% responders were being utilized as surveillance tools for HCC. One-quarter of practitioners were not familiar with the AASLD surveillance guidelines. This practitioners surveyed reported that lack of access to radiology services was the most common barrier to screening. The practitioners who had a better and more compliant surveillance practice had more than 25% of their patients being Asian. These practitioners also had a history of being active in vaccinating for hepatitis B or hepatitis A as well as a knowledge base that identified those individuals at high-risk for HCC. These practitioners were also aware of national screening and surveillance guidelines that had been published by national organizations. The authors concluded that HCC surveillance by providers was dependent on the prevalence of at-risk patients within a given practice and provider knowledge. This abstract highlights the need for community education to improve screening practices for HCC. "Early detection and predictors of hepatocellular carcinoma in a prospective cohort study of patients with cirrhosis in the U.S."Abstract 1462, Singal. This group identified at a single center that the incidence of HCC in their screening population, patients with cirrhosis, was 2.4 per 100 person/years. Elevated baseline AFP, Child's B or C cirrhosis and male gender were associated with increased risk. The use of statins for hyperlipidemia was associated with a decreased risk of HCC. They also demonstrated that ultrasound and alpha fetoprotein were complimentary in triggering further evaluations that led to the diagnosis of HCC in an early stage of 75% of patients