Introduction It is thought that mortality due to hepatocellular carcinoma (HCC) is rising in the Western world. This has been primarily attributed to the hepatitis C viral epidemic.1 HCC detected after the development of symptoms carries an extremely poor prognosis (0–10 per cent survival at 5 years),2 whereas those detected at surveillance can often be cured. One study demonstrated reduced mortality of 37% in cirrhotic patients undergoing 6 monthly surveillance with ultrasound scanning (USS) and α fetoprotein (AFP) levels; this method is currently recommended by the BSG.3 However, the American Association for the study of Liver Diseases (AASLD) now advocates 6 monthly USS without AFP testing: studies showed that AFP levels increased detection rate but also increased false positive detection rates with an added cost of $2000 to $3000 per tumour found.4 The clinical lead for hepatology in Swansea, Dr C L Ch'ng, has primarily adopted these guidelines.
Methods A list of 246 patients entered into the HCC surveillance programme between January 2006 and December 2011 was reviewed and the frequency of USS and AFP levels measured for each patient was recorded. 62 patients were excluded:
14 new patients
13 had insufficient data
12 developed serious comorbidities or died before follow-up was complete
3 were inappropriate for surveillance
Results were compared with standards set by BSG and AASLD guidelines.
Results 184 patients were appropriate for surveillance
183 had at least 1 USS
168 had at least 2 USS
114 had 6–12 monthly USS
95 (52%) had 6 monthly USS (recommended by AASLD)
48 (26%) received 6 monthly USS and AFP levels (current BSG recommendation).
Conclusion Surveillance of cirrhotic patients for HCC is currently suboptimal, with poor adherence to national guidelines. There is evidence that patients engaged initially but timing of subsequent USS and AFP teasting was erratic. Despite this, results are favourable in comparison with a large US study of cirrhotic hepatitis C carriers which demonstrated routine surveillance in only 12% of patients. Results did not differ widely from similar departmental audits carried out in the last 5 years. Suggestions for the future include routine 6 monthly postal invitation to screening with facilitated access to scans, together with education of both patients and treating clinicians regarding HCC risk. This should ideally be carried out within an established local surveillance scheme.
Competing interests None declared.
References 1. Serag HB, Mason AC. Rising incidence of hepatocellular carcinoma in the United States. N Engl J Med 1999;340:745–50.
2. Llovet JM, et al. Hepatocellular carcinoma. Lancet 2003;362:1907–17.
3. Ryder SD. Guidelines for the diagnosis and treatment of HCC in adults. Gut 2003;362:1907–17.
4. Santagostino E, et al. A 6-month versus a 12-month surveillance for hepatocellular carcinoma in 559 haemophiliacs infected with the hepatitis C virus. Blood 2003;102:78–82.