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Effectiveness of AFP and ultrasound tests on hepatocellular carcinoma mortality in HCV-infected patients in the USA
  1. Hashem B El-Serag1,2,
  2. Jennifer R Kramer1,
  3. G John Chen1,
  4. Zhigang Duan1,
  5. Peter A Richardson1,
  6. Jessica A Davila1
  1. 1Houston Center for Quality of Care & Utilization Studies, Sections of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
  2. 2Gastroenterology and Hepatology section at the Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas, USA
  1. Correspondence to Hashem B El-Serag, The Michael E DeBakey VA Medical Center, 2002 Holcombe Blvd. (152), Houston, TX 77030, USA; hasheme{at}


Background and aims The effectiveness of surveillance for hepatocellular carcinoma (HCC) in the USA is largely unknown. The objective of this study was to evaluate the effectiveness of HCC surveillance in a national Veterans Administration (VA) practice setting, using the national VA hepatitis C virus (HCV) Clinical Case Registry.

Method The cohort consisted of 1480 HCV-infected patients who developed HCC during 1998–2007. The timing and intensity of receiving α-fetoprotein (AFP) and abdominal ultrasound (US) for HCC surveillance were evaluated. Overall mortality risk was examined using Cox proportional hazards regression models adjusting for demographics, clinical features and receipt of HCC-specific treatment.

Results The mean survival was 1.8 years following the HCC diagnosis date. Surveillance AFP or US were recorded in 77.8% of patients within 2 years prior to HCC diagnosis. Annual surveillance with both AFP and US was observed in only 2% of patients. The presence of either AFP or US surveillance during both 0–6 month and 7–24 month periods before HCC diagnosis was associated with a lower mortality risk (HR 0.71, 95% CI 0.62 to 0.82) compared with no surveillance. Receipt of two or more surveillance tests in the 0–6 months (HR 0.76 95% CI 0.66 to 0.88) and to a lesser extent in the 7–12 months (HR 0.81 95% CI 0.1 to 0.99) prior to HCC diagnosis was also associated with reduced mortality risk.

Conclusions Most patients with HCV-related cirrhosis do not receive regular imaging-based surveillance. The effectiveness of HCC surveillance tests in current clinical practice is rather modest in reducing HCC-related mortality.

  • Hepatocellular carcinoma
  • cirrhosis
  • AFP
  • ultrasound
  • surveillance
  • hepatocellular carcinoma
  • liver imaging
  • ultrasonography

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  • Funding This work was supported in part by the Houston VA HSR&D Center of Excellence (HFP90-020), National Institute of Diabetes and Digestive and Kidney Disease, Center grant DK56338, and the National Cancer Institute (R01-CA-125487). In addition, JRK is the recipient of a VA Health Services and Development MREP award (MRP05-305). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Veterans Affairs, Baylor College of Medicine, The University of Texas School of Public Health or the National Cancer Institute.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Baylor College of Medicine IRB.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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