Hepatocellular carcinoma

Abstract

Alejandro Forner and colleagues (March 31, p 1245)1Forner A Llovet JM Bruix J Hepatocellular carcinoma.Lancet. 2012; 379: 1245-1255Summary Full Text Full Text PDF PubMed Scopus (3577) Google Scholar advocate for screening of hepatocellular carcinoma despite no evidence of benefit, arguing that a “validation trial in developed regions is not feasible”. Only two randomised trials are available, both from China: one is negative, the other is positive but has several major flaws.2Lederle FA Pocha C Screening for liver cancer: the rush to judgment.Ann Intern Med. 2012; 156: 387-389Crossref PubMed Scopus (67) Google Scholar From developed countries, only observational studies are available. These conclude that screening improves survival despite the raw data showing that screened patients die younger than do non-screened patients (length time and lead time biases).3Braillon A Screening for hepatocellular carcinoma: from lack of evidence to common sense.Hepatology. 2010; 52: 1863-1864Crossref PubMed Scopus (11) Google Scholar Last, there is no agreement on the screening method because varying imaging techniques with various intervals have been used. Screening is a complex issue which necessitates a national programme to ensure minimum participation, quality controls, and evaluation of the results. None of these is currently in place in any country. Only 12% of US patients with viral cirrhosis are screened,4Braillon A Surveillance for hepatocellular carcinoma.Ann Intern Med. 2011; 155: 274-275Crossref PubMed Scopus (1) Google Scholar which is probably because the National Cancer Institute states that: “based on fair evidence, screening would not result in a decrease in mortality from HCC…” but “would result in rare but serious side effects”.5National Cancer InstituteUS National Institutes of HealthLiver (hepatocellular) cancer screening (PDQ).http://www.cancer.gov/cancertopics/pdq/screening/hepatocellular/HealthProfessional/page2Google Scholar Patients deserve evidence-based medicine. Why can hepatologists in developed countries not do randomised trials for hepatocellular carcinoma to investigate the benefits and harms of screening, as gastroenterologists have done for colorectal cancer and urologists for prostate cancer? Recruitment is not an issue: hepatocellular carcinoma is the fifth most common cancer in the world. I declare that I have no conflicts of interest. Hepatocellular carcinoma – Authors' replyIn answer to Alain Braillon, we openly exposed the limited scientific evidence to support screening for hepatocellular carcinoma and commented on the challenges a controlled trial would face. An Australia survey1 showed that 99% of patients refused to enter a screening versus no screening trial. Even if up to 5% accepted, such a proportion would not be representative and results would be questioned by those wanting high-level evidence. The bulk of available information suggests that screening is beneficial. Full-Text PDF