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Cited by 266Hepatocellular Carcinoma Treatment and PrognosisLiver Disease Diagnosis and TreatmentGlobal Cancer Incidence and Screening

An assessment of benefits and harms of hepatocellular carcinoma surveillance in patients with cirrhosis

Open access
Atiq, Omair, Tiro, Jasmin, Yopp, Adam C., Muffler, Adam, Marrero, Jorge A., Parikh, Neehar D., Murphy, Caitlin, McCallister, Katharine +1 more·2017·Hepatology
DOI 10.1002/hep.28895PMC PMC5659110
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Abstract

Although surveillance ultrasound and alpha fetoprotein (AFP) tests have minimal direct harm, downstream harms from follow-up tests must be weighed against surveillance benefits when determining the value of hepatocellular carcinoma (HCC) screening programs. Our study's aims were to characterize prevalence and correlates of surveillance benefits and harms in cirrhosis patients undergoing HCC surveillance. We conducted a retrospective cohort study among patients with cirrhosis followed at a safety-net health system between July 2010 and July 2013. We recorded surveillance-related benefits, defined as early tumor detection and curative treatment, and surveillance-related physical harms, defined as computed tomography or magnetic resonance imaging scans, biopsies, or other procedures performed for false-positive or indeterminate surveillance results. Sociodemographic and clinical correlates of surveillance harms were evaluated using multivariable logistic regression. We identified 680 patients with cirrhosis, of whom 78 (11.5%) developed HCC during the 3-year study period. Of the 48 (61.5%) HCCs identified by surveillance, 43.8% were detected by ultrasound, 31.2% by AFP, and 25.0% by both surveillance tests. Surveillance-detected patients had a higher proportion of early HCC (70.2% vs. 40.0%; P = 0.009), with no difference in tumor stage between ultrasound- and AFP-detected tumors (P = 0.53). Surveillance-related physical harms were observed in 187 (27.5%) patients, with a higher proportion of ultrasound-related harm than AFP-related harm (22.8% vs. 11.4%; P < 0.001). Surveillance-related harms were associated with elevated ALT (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.26-2.76), thrombocytopenia (OR, 2.06; 95% CI, 1.26-3.38), and hepatology subspecialty care (OR, 1.63; 95% CI, 1.09-2.42). CONCLUSION: Over one fourth of patients with cirrhosis experience physical harm for false-positive or indeterminate surveillance tests-more often related to ultrasound than AFP. Interventions are needed to reduce surveillance-related harm to increase the value of HCC screening programs in clinical practice. (Hepatology 2017;65:1196-1205).

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  • Ultrasound-based surveillance has low sensitivity for detection of hepatocellular carcinoma at an early stage, particularly in adults with MASLD-related cirrhosis and obesity.

    “As ultrasound-based surveillance has a low sensitivity for detection of hepatocellular carcinoma at an early-stage, particularly in adults with MASLD-related cirrhosis and obesity, alpha-fetoprotein (AFP) measurement can be combined with ultrasound in individuals at high risk ( LoE 3, open recommendation, consensus ).”

    From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [251]

    The Discussion (page not available) describes suboptimal sensitivity for early tumor detection, and the Benefits of HCC Surveillance section reports that some tumors were detected by AFP alone rather than ultrasound. The paper does not establish that ultrasound sensitivity is particularly low in adults with MASLD-related cirrhosis and obesity; its discussion of NASH concerns a possible increase in ultrasound-related harms, not a measured sensitivity difference. (LLM, conf=0.86)

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  • Individuals with MASLD have increased odds of persistent poor visualisation with a pooled sensitivity of 45% for ultrasound alone and increased risk of false positive or indeterminate results.

    “However, individuals with MASLDhaveincreasedoddsofpersistentpoorvisualisation with a pooled sensitivity of 45% for ultrasound alone and increased risk of false positive or indeterminate results. 250,251”

    From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [251]

    The Correlates of Physical Harms section (page not provided) associates non-viral cirrhosis etiologies with increased ultrasound-related harm from false-positive or indeterminate results. It does not establish that risk specifically for MASLD. The paper also does not report persistent poor visualisation in MASLD or a pooled 45% sensitivity for ultrasound alone. (LLM, conf=0.86)

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  1. American Cancer Society. Global Cancer Facts & Figures 3rd Edition. Atlanta: American Cancer Society; 2015

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Authors
Atiq, O., Tiro, J., Yopp, A. C., Muffler, A., Marrero, J. A., Parikh, N. D., Murphy, C., McCallister, K., & Singal, A. G.
Affiliations
  • Parkland Health & Hospital System (US)
  • Harold C. Simmons Comprehensive Cancer Center (US)
  • University of Michigan (US)
  • The University of Texas Southwestern Medical Center (US)
Corresponding author
Singal, Amit G.
ORCID
Venue
Hepatology
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2016-12-19
Volume
65
Issue
4
Pages
1196-1205
ISSN
  • 0270-9139 (ISSN-L)
  • 1527-3350
DOI
10.1002/hep.28895
PMC
PMC5659110
OpenAlex
W2544387958
Cited by
266
References
38
Citations by year
2026: 13 · 2025: 26 · 2024: 29 · 2023: 43 · 2022: 27 · 2021: 30 · 2020: 38 · 2019: 23 · 2018: 20 · 2017: 16 · 2016: 1
FWCI
14.47
Type
journal article
Language
en
Open access
Licence
Locations
  • Hepatology (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • Deep Blue (University of Michigan) (submittedVersion)
Funders
  • National Institutes of Health
  • Agency for Healthcare Research and Quality (HS022418, R24HS022418)
Topics
  • Health Sciences › Medicine › Hepatology › Hepatocellular Carcinoma Treatment and Prognosis
  • Health Sciences › Medicine › Epidemiology › Liver Disease Diagnosis and Treatment
  • Health Sciences › Medicine › Oncology › Global Cancer Incidence and Screening
Keywords
hepatocellular carcinoma, liver cirrhosis, cancer surveillance, ultrasound surveillance, false positives, indeterminate results, early cancer detection, curative treatment, safety-net health system, thrombocytopenia, ALT elevation, screening program evaluation
MeSH terms
Adult, alpha-Fetoproteins, Cell Transformation, Neoplastic, Female, Carcinoma, Hepatocellular, Humans, Liver Cirrhosis, Liver Function Tests, Liver Neoplasms, Male, Mass Screening, Middle Aged, Prognosis, Retrospective Studies, Cohort Studies, Multivariate Analysis, Odds Ratio, Risk Assessment, Ultrasonography, Doppler, Early Detection of Cancer

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