Yield of Alpha Fetoprotein on Patients with Hepatocellular Cancer in Veteran Population

Abstract

Purpose: Hepatocelluar cancer (HCC) is increasingly recognized at an earlier stage as a consequence of the routine screening of cirrhotic patients by serum alpha fetoprotein (AFP) and liver imaging. AFP has recently been removed as a screening tumor marker by the American Association of Society for Liver Disease. Recent data indicates that it may still hold prognostic value on survival among patients with hepatitis C virus (HCV)-related HCC. We aim to study the yield of AFP levels in patients with HCC to determine if elevated levels impact survival. Methods: After IRB approval, all patients diagnosed with HCC between January, 2000 and December, 2010 at Dayton VA Medical Center were identified through electronic patient database. Demographic, imaging, laboratory, and treatment information was abstracted. Results: We identified 63 patients with HCC who underwent serial AFP testing. All study subjects were male; 63% were white, 35% black, and no racial group identified in the remainder. The median age at HCC diagnosis was 60 years (range 42-87 years). The median length of follow-up was 10.3 months. The overall median survival after HCC diagnosis was 8.8 months. Forty-nine (78%) patients had biopsyproven HCC. The average tumor size at diagnosis was 5.6 cm, with tumor greater than 2 cm in 76% patients. Multifocal disease at diagnosis was noted in 32% of patients. Hepatitis B and hepatitis C virus infection was seen in 46% and 63%, respectively. The median AFP level at diagnosis was 18.9 ng/mL (Range <5 to 26,191 ng/mL). AFP levels were determined within 60 days in 89% patients. AFP at time of diagnosis was <10 ng/mL in 43%, 10-100 ng/mL in 33%, 100-1,000 ng/mL in 13%, and >1000 ng/mL in 6%, with median survival of 9.2, 14, 9.5, and 5.3 months, respectively. Overall, 17% of patients had AFP >200 ng/mL, and 6 months survival in this group was 36%, compared to 67% in those with AFP <200 ng/mL. Median survival associated with HCV-related HCC was 12 months, vs 10 months for those without HCV. There was no difference in the median AFP levels in the two groups. HCC was treated with locoregional therapy, including trans-arterial chemoembolization and/or by radiofrequency ablation in 73% of patients. Systemic chemotherapy with sorafenib was used in 16%. Three patients underwent surgical resection. Patients who showed decrease in AFP in response to therapy had a median survival of 20 months, vs 10.3 months in non-responders. Conclusion: Patients with tumor ≥ 5 cm and those with multifocal HCC were more likely to have higher levels of AFP at diagnosis. AFP levels ≥ 200 ng/ml at diagnosis were associated with reduced survival. Co-morbidities, including HCV, diabetes, and obesity were not associated with increased mortality in our study population.