Abstract
The article1Stravitz R.T. Heuman D.M. Chand N. et al.Surveillance for hepatocellular carcinoma in patients with cirrhosis improves outcome.Am J Med. 2008; 121: 119-126Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar concerning hepatocellular carcinoma (HCC) in the January issue of the Journal needs several clarifications. There are 2 nonrandomized interventions (screening and transplantation) leading to serious selection biases. The group definition was retrospective and misleading: Computed tomography and magnetic resonance imaging are not part of “standard-of-care surveillance.” Why were the data for the 27 patients in the HCC group (discovered incidentally on explant pathology) not presented? Last, how many patients were studied, 269 or 279 (sum of the 3 groups)? The possibility of a lead-time bias was ruled out without discussion or data (ie, mean age at death). Numerous studies investigated screening; all were negative or inconclusive. In the most recent study, screened patients died 18 months younger than nonscreened patients. Nevertheless, the authors concluded that screening improved survival!2Trevisani F. Santi V. Gramenzi A. et al.Surveillance for early diagnosis of hepatocellular carcinoma: is it effective in intermediate/advanced cirrhosis?.Am J Gastroenterol. 2007; 102: 2448-2457Crossref PubMed Scopus (80) Google Scholar There are several potentially (no randomized controlled trials available) curative treatments for small HCC: transplantation, resection, and local ablation. Their respective place is largely debated. Transplantation is not the panacea. In large series, survival for patients with small HCCs is lower than for other indications, an unacceptable result considering the shortage of organs. Present diagnostic and treatment strategies are difficult to understand. Fear of malpractice lawsuits is not the explanation because the recommendation has a low-grade rating and was elaborated without public health expertise. Hope is no longer justified. The “I can do it, then I do it” attitude will not mask our ignorance indefinitely. Present practices are unlikely to change without new data. National agencies must actively promote and support properly designed scientific studies. They are possible. Two treatments are evidence based from randomized controlled trials: chemoembolization in patients with unresectable HCC and sorafenib in a palliative indication.3Llovet M. Burroughs A. Bruix J. Hepatocellular carcinoma.Lancet. 2003; 362: 1907-1917Abstract Full Text Full Text PDF PubMed Scopus (3769) Google Scholar, 4Abou-Alfa G.H. Schwartz L. Ricci S. et al.Phase II study of sorafenib in patients with advanced hepatocellular carcinoma.J Clin Oncol. 2006; 24: 4293-4300Crossref PubMed Scopus (1093) Google Scholar They are feasible; recruiting is not an issue. HCC is the fifth most common cause of cancer. Screening advocates must understand that poor evidence is a leading cause of poor compliance, a situation precluding efficiency for any screening policies.
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