Utility and cost-effectiveness of screening for hepatocellular carcinoma in a resource-limited setting.

Abstract

With great interest, we read the paper ‘‘Utility and costeffectiveness of screening for hepatocellular carcinoma in a resource-limited setting’’ by Eltabbakh et al. published in Med Oncol, 32 (1) in January 2015 [1]. We would like to make the following comments. This report tried to prove the utility, efficacy and cost-effectiveness of the screening program for hepatocellular carcinoma (HCC), wherein they established a screening program that combined ultrasound and AFP level. They discovered that screening for HCC is feasible and highly cost effective in a resource-limited setting. Additionally, they recommended all patients with liver cirrhosis to join the surveillance program in developing and resource-limited countries. As we know, China is the largest developing country and suffers over 50 % HCCs of the world due to the high prevalence of the hepatitis B virus (HBV) infection [2]. Thus, this paper would be a guideline for HCC screening in China. As we know, HCC is the fifth most common cancer and second leading cause of cancer-related deaths worldwide [3]. The curative therapy includes liver resection, ablation, and liver transplantation. However, over 60 % HCC patients drop out from these radical therapies due to overly advanced stage [4]. Therefore, a convenient, efficient and cost-effective screening program for HCC would improve the long-term outcomes of HCC patients. Previously, HBV infection or liver cirrhosis was screened via AFP, ultrasound, and liver function evaluation every 3–5 months, which is frequent but less regular than the study by Eltabbakh et al. The main reason may be the higher rate of HBV infection but lack of medical resources and compliance in China. Although EASL and AASLD guidelines recommend screening every 6 months, we recommend ultrasound combined with AFP level screening at least every 4 months. HCC progresses fast and may advance from an early stage to an advanced stage within 3 months [5]. As stated in this paper, 11 patients were detected with BCLC stage D even with the screening. Suspicion of HCC was raised by the detection of a hepatic focal lesion in ultrasound examination; then, enhanced CT or MRI was performed to confirm the diagnosis. Biopsy was performed to confirm when the imaging scan was unable distinguish between cirrhosis node and HCC target. We deeply appreciate the cost-effective assessment as shown in Table 3. According to WHO, cost-effectiveness should be based on the GDP: Cost/QALY is \3 times the GDP. However, the authors included the cost of screening and treatment of HCC only, excluding the cost of the antivirus therapy: Most of these cases had HCV infection and few cases had HBV infection, so the actual overall cost may include the anti-virus therapy costs. Furthermore, the most important consideration for HCC patients is the longterm overall survival, which was ignored by the authors. We think adding the long-term overall survival data will help strengthen this paper. In conclusion, screening for HCC via combined AFP level and ultrasound is a feasible and highly cost-effective method in China.