Hepatocellular Carcinoma Surveillance In Hepatitis C Patients: How Are We Doing?

Abstract

Purpose: In the U.S., hepatitis C virus (HCV) is the number one cause of death from liver disease and the number one indication for liver transplantation. Those with HCV are at increased risk for hepatocellular carcinoma (HCC), the ninth leading cause of cancer-related death in the U.S. The current guideline from the American Association for the Study of Liver Diseases (AASLD) for HCC surveillance in HCV patients is performance of abdominal ultrasound every 6 months in HCV cirrhosis patients only. As of 2010, the AASLD no longer recommends serum alpha fetoprotein (AFP) testing as an HCC screening tool. We examined whether we are following HCC screening guidelines in the setting of the outpatient hepatology clinic. Methods: A systematic chart review was performed. Using a random date generator, patient charts were selected from hepatology clinic days. Only mono-infected patients with HCV were included. Patients who were co-infected with hepatitis B or HIV, had another liver diagnosis, were post-transplant, and/or required abdominal imaging for other clinical reasons were excluded. An appropriate screening interval was defined as 6 +/- 2 months (4 to 8 months). Cirrhotic patients were identified by use of the term “cirrhosis” in clinic notes only. Results: Fifty-three patients met the inclusion criteria over 8 days sampled. Of these 53 patients, 16 were identifi ed as cirrhotic, and 37 as non-cirrhotic. All of the 16 cirrhotic patients (100%) had imaging; however, seven (43.8%) were imaged less frequently than the defined interval, and 11 (68.8%) had serum AFP levels drawn. Of the 37 non-cirrhotic patients, 23 (62.2%) had imaging, and 26 (70.3%) had serum AFP levels drawn. Conclusion: Patients with non-cirrhotic HCV are likely being over-screened for HCC in the clinic setting. Additionally, serum AFP levels continue to be used for surveillance, even though these have been dropped from the guidelines. Over-screening with either imaging or serum AFP may account for inappropriate allocation of healthcare dollars and increased morbidity in patients undergoing unnecessary follow-up testing, such as CT scans. More thorough investigation of the non-cirrhotic patients may be necessary, as these patients may have “advanced fibrosis,” and thus qualify for screening under European Association for the Study of the Liver (EASL) guidelines. All patients with HCV cirrhosis are receiving imaging surveillance, but some less frequently than recommended, increasing the risk of advanced-stage HCC diagnosis. Administrative practices may need to be implemented to ensure strict follow-up with HCV cirrhosis patients. Further investigation is recommended to examine if some or all of our findings are prevalent in other hepatology clinics nationwide.