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Lee J, Park SB, Byun S, Kim HI. Impact of ultrasonographic blind spots for early-stage hepatocellular carcinoma during surveillance. PLoS One 2022; 17:e0274747. [PMID: 36112645 PMCID: PMC9481035 DOI: 10.1371/journal.pone.0274747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Abdominal ultrasonography (US) is the backbone of hepatocellular carcinoma (HCC) surveillance. Although previous studies have evaluated clinical factors related to surveillance failure, none have focused specifically on US blind spots.
Methods
This study included 1,289 patients who underwent 6 months intervals surveillance using US and serum alpha-fetoprotein (AFP) and were eventually diagnosed with single-nodular HCC. Patients were divided into US-detected group (n = 1,062) and US-missed group (HCC detected only by AFP ≥ 20ng/mL; n = 227). Blind spots consisted of four locations: hepatic dome, caudate lobe or around the inferior vena cava, <1 cm beneath the ribs, and the surface of the left lateral segment. Both groups were compared by HCC location, proportional distribution, treatment method, and overall survival.
Results
A higher proportion of HCCs were located within blind spots in the US-missed group than in the US-detected group (64.3% vs. 44.6%, P < 0.001). HCC ≥ 2 cm detected in blind spots was higher than in non-blind areas (60.3% vs. 47.1%, P = 0.001). Blind spot HCCs were more treated with surgery, whereas those located in a non-blind area were more treated with local ablation. Patients with an HCC located within a blind spot in the US-detected group had better overall survival than the same in the US-missed group (P = 0.008).
Conclusions
Using the current surveillance test, blind spots affected the initially detected HCC tumor size, applicability of the treatment modality, and overall survival. Physicians should pay attention to US blind spots when performing US-based HCC surveillance.
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Affiliation(s)
- Junghwan Lee
- Department of Gastroenterology, Asan Medical Center, Seoul, South Korea
| | - Su Bee Park
- Department of Gastroenterology, Asan Medical Center, Seoul, South Korea
| | - Soyoung Byun
- Department of Gastroenterology, Asan Medical Center, Seoul, South Korea
| | - Ha Il Kim
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
- * E-mail:
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Nguyen ALT, Nguyen HTT, Yee KC, Palmer AJ, Blizzard CL, de Graaff B. A Systematic Review and Narrative Synthesis of Health Economic Evaluations of Hepatocellular Carcinoma Screening Strategies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:733-743. [PMID: 33933243 DOI: 10.1016/j.jval.2020.11.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 09/24/2020] [Accepted: 11/17/2020] [Indexed: 05/02/2023]
Abstract
OBJECTIVES Many economic evaluations of hepatocellular carcinoma (HCC) screenings have been conducted; however, these vary substantially with regards to screening strategies, patient group, and setting. This review aims to report the current knowledge of the cost-effectiveness of screening and describe the published data. METHODS We conducted a search of biomedical and health economic databases up to July 2020. We included full and partial health economic studies if they evaluated the costs or outcomes of HCC screening strategies. RESULTS The review included 43 studies. Due to significant heterogeneity in key aspects across the studies, a narrative synthesis was conducted. Most studies reported using ultrasound or alpha fetoprotein as screening strategies. Screening intervals were mostly annual or biannual. Incidence, diagnostic performance, and health state utility values were the most critical parameters affecting the cost-effectiveness of screening. The majority of studies reported HCC screening to be cost-effective, with the biannual ultrasound + alpha fetoprotein standing out as the most cost-effective strategy. However, few studies considered the utilization rate, and none considered the diagnostic performance of ultrasound in the context of central adiposity. Computed tomography and magnetic resonance imaging were also evaluated, but its cost-effectiveness was still controversial. CONCLUSIONS Although many studies suggested HCC screening was cost-effective, substantial limitations of the quality of these studies means the results should be interpreted with caution. Future modeling studies should consider the impact of central adiposity on the precision of ultrasound, real-world utilization rates and projections of increased HCC incidence.
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Affiliation(s)
- Anh Le Tuan Nguyen
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Hoa Thi Thu Nguyen
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Kwang Chien Yee
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Barbara de Graaff
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia.
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Abstract
INTRODUCTION The value of hepatocellular carcinoma (HCC) surveillance is defined by the balance of benefits, i.e., early tumor detection, and potential harms, related to false positive and indeterminate results. Although physical harms can be observed in 15%-20% of patients with cirrhosis undergoing HCC surveillance, previous cost-effectiveness analyses have not incorporated costs of harms. We aimed to evaluate the cost-effectiveness of HCC surveillance including both benefits and harms. DESIGN We constructed a Markov model to compare surveillance strategies of ultrasound (US) alone, US and alpha fetoprotein (AFP), and no surveillance in 1 million simulated patients with compensated cirrhosis. Harms included imaging and biopsy in patients undergoing surveillance for HCC. Model inputs were based on literature review, and costs were derived from the Medicare fee schedule, with all costs inflated to 2018 dollars. The primary outcome was the incremental cost-effectiveness ratio per incremental quality-adjusted life-year. RESULTS In the base case analysis, US with AFP was the dominant strategy over both US alone and no surveillance. In a probabilistic sensitivity analysis, US with AFP was the most cost-effective strategy in 80.1% of simulations at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year. In our threshold analyses, an HCC incidence >0.4% per year and surveillance adherence >19.5% biannually were necessary for US with AFP to be cost-effective compared with no surveillance. DISCUSSION Accounting for both surveillance-related benefits and harms, US and AFP is more cost-effective for HCC surveillance than US alone or no surveillance in patients with compensated cirrhosis.
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Farhang Zangneh H, Wong WWL, Sander B, Bell CM, Mumtaz K, Kowgier M, van der Meer AJ, Cleary SP, Janssen HLA, Chan KKW, Feld JJ. Cost Effectiveness of Hepatocellular Carcinoma Surveillance After a Sustained Virologic Response to Therapy in Patients With Hepatitis C Virus Infection and Advanced Fibrosis. Clin Gastroenterol Hepatol 2019; 17:1840-1849.e16. [PMID: 30580095 DOI: 10.1016/j.cgh.2018.12.018] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 11/20/2018] [Accepted: 12/10/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Hepatitis C virus (HCV)-related cirrhosis increases the risk for hepatocellular carcinoma (HCC). After a sustained virologic response (SVR) to anti-HCV therapy, the risk of HCC is reduced but not eliminated. Recent developments in antiviral therapy have increased rates of SVR markedly. Guidelines recommend indefinite biannual ultrasound surveillance after SVR for patients with advanced fibrosis before treatment. Surveillance for HCC is cost effective before anti-HCV treatment; we investigated whether it remains so after SVR. METHODS We developed a Markov model to evaluate the cost effectiveness of biannual or annual HCC ultrasound surveillance vs no surveillance in 50-year-old patients with advanced fibrosis after an SVR to anti-HCV therapy. Parameter values were obtained from publications and expert opinions. Primary outcomes were quality-adjusted life-years (QALYs), costs, and the incremental cost-effectiveness ratios (ICERs). RESULTS With a constant 0.5% annual incidence of HCC, biannual and annual surveillance resulted in ICERs of $106,792 and $72,105 per QALY, respectively, with high false-positive rates. When surveillance was limited to patients with cirrhosis, but not F3 fibrosis, biannual surveillance likely was cost effective, with ICERs of $48,729 and $43,229 per QALY after treatment with interferon and direct-acting antiviral agents, respectively. In patients with F3 fibrosis, the incidence of HCC was 0.3% to 0.4% per year, leading to an ICER of $188,157 per QALY for biannual surveillance. If HCC incidence increases with age, surveillance becomes more cost effective but remains below willingness-to-pay thresholds only for patients with cirrhosis or with pretreatment aspartate aminotransferase to platelet ratio index greater than 2.0 or FIB-4 measurements greater than 3.25. Sensitivity analyses identified HCC incidence and transition rate to symptomatic disease without surveillance as factors that affect cost effectiveness. CONCLUSIONS In a Markov model, we found HCC surveillance after an SVR to HCV treatment to be cost effective for patients with cirrhosis, but not for patients with F3 fibrosis.
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Affiliation(s)
- Hooman Farhang Zangneh
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Public Health Ontario, Ontario, Canada
| | - Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Khalid Mumtaz
- Wexner Medical Center, Ohio State University, Columbus, Ohio
| | - Matthew Kowgier
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Sean P Cleary
- Department of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Kelvin K W Chan
- Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada; Canadian Centre for Applied Research in Cancer Control, Vancouver, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Hassan M, Husen Y, Abbasi SUN, Hussain Z. Diagnostic Accuracy of Multidetector Computed Tomography in Detection of Esophageal Varices. Cureus 2019; 11:e3933. [PMID: 30931201 PMCID: PMC6430303 DOI: 10.7759/cureus.3933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Objective To determine the diagnostic accuracy of multidetector computed tomography (MDCT) in the detection of esophageal varices by taking endoscopy as the reference standard. Materials and methods This was a cross-sectional prospective study conducted at the Department of Radiology, Aga Khan University Hospital, (AKUH) Karachi, for the duration of 12 months from August 1, 2014 to July 31, 2015. One hundred ninety-six patients with a suspicion of chronic liver disease/cirrhosis undergoing 64 slice MDCT were enrolled in our study and underwent computed tomography (CT) scanning in the Department of Radiology at AKUH. Biphasic CT was performed with images obtained during the hepatic arterial phase (30-second delay) and the portal venous phase (65-second delay) after the intravenous (IV) injection of 120 mL of nonionic contrast material at a rate of 3.5 mL/s. The presence of esophageal varices was evaluated on MDCT with endoscopy as gold standard. The sensitivity, specificity, negative predictive value and positive predictive value, and accuracy of MDCT were assessed against the gold standard. Results Our results yielded an MDCT sensitivity of 98.96%, specificity of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 66.67%, and diagnostic accuracy of 98.97% for esophageal varices in chronic liver disease (CLD) patients. Conclusion The rate of detection of esophageal varices in patients with chronic liver disease on MDCT in our country is comparable to the international data and we advocate that MDCT should be used as a screening tool in patients with chronic liver disease to exclude esophageal varices.
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Affiliation(s)
| | - Yousuf Husen
- Radiology, The Agha Khan University Hospital, Karachi, PAK
| | | | - Zainab Hussain
- Radiology, The Aga Khan University Hospital, Karachi, PAK
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Abstract
Hepatocellular carcinoma (HCC) is a major cause of cancer death and is increasing in incidence. This review focuses on HCC surveillance and treatment of early-stage disease, which are essential to improving outcomes. Multiple societies have published HCC surveillance guidelines, but screening efforts have been limited by noncompliance and overall lack of testing for patients with undiagnosed chronic liver disease. Treatment of early-stage HCC has become increasingly complex due to expanding therapeutic options and better outcomes with established treatments. Surgical indications for HCC have broadened with improved preoperative liver testing, neoadjuvant therapy, portal vein embolization, and perioperative care. Advances in post-procedural monitoring have improved efficacies of transarterial chemoembolization and radiofrequency ablation, and novel therapies involving delivery of radiochemicals are being studied in small trials. Finally, advances in liver transplantation have allowed for expanded indications beyond Milan criteria with non-inferior outcomes. More clinical trials evaluating new therapies and multimodal regimens are necessary to help clinicians design better treatment algorithms and improve outcomes.
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Affiliation(s)
| | - Kenneth K Tanabe
- Harvard Medical School.,Division of Surgical Oncology.,Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, Boston, MA, USA
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7
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Affiliation(s)
- Necati Örmeci
- Department of Gastroenterology, Ankara University Medical School, Ankara, Turkey.
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8
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Maida M, Malizia G, Affronti A, Virdone R, Maida C, Margherita V, D’amico G. Screening and surveillance for hepatocellular carcinoma: perspective of a new era? Expert Rev Anticancer Ther 2016; 16:1291-1302. [PMID: 27730841 DOI: 10.1080/14737140.2016.1246965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Marcello Maida
- Section of Gastroenterology, Villa Sofia, V. Cervello Hospital, Palermo, Italy
| | - Giuseppe Malizia
- Section of Gastroenterology, Villa Sofia, V. Cervello Hospital, Palermo, Italy
| | - Andrea Affronti
- Section of Internal Medicine, Villa Sofia, V. Cervello Hospital, Palermo, Italy
| | - Roberto Virdone
- Section of Internal Medicine, Villa Sofia, V. Cervello Hospital, Palermo, Italy
| | - Carlo Maida
- Section of Internal Medicine, DIBIMIS, University of Palermo, Palermo, Italy
| | - Vito Margherita
- Department of Medical Sciences, Surgical and Advanced Technologies, University of Catania, Catania, Italy
| | - Gennaro D’amico
- Section of Gastroenterology, Villa Sofia, V. Cervello Hospital, Palermo, Italy
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9
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Llovet JM, Zucman-Rossi J, Pikarsky E, Sangro B, Schwartz M, Sherman M, Gores G. Hepatocellular carcinoma. Nat Rev Dis Primers 2016; 2:16018. [PMID: 27158749 DOI: 10.1038/nrdp.2016.18] [Citation(s) in RCA: 1693] [Impact Index Per Article: 211.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Liver cancer is the second leading cause of cancer-related deaths globally and has an incidence of approximately 850,000 new cases per year. Hepatocellular carcinoma (HCC) represents approximately 90% of all cases of primary liver cancer. The main risk factors for developing HCC are well known and include hepatitis B and C virus infection, alcohol intake and ingestion of the fungal metabolite aflatoxin B1. Additional risk factors such as non-alcoholic steatohepatitis are also emerging. Advances in the understanding of the molecular pathogenesis of HCC have led to identification of critical driver mutations; however, the most prevalent of these are not yet druggable targets. The molecular classification of HCC is not established, and the Barcelona Clinic Liver Cancer staging classification is the main clinical algorithm for the stratification of patients according to prognosis and treatment allocation. Surveillance programmes enable the detection of early-stage tumours that are amenable to curative therapies - resection, liver transplantation or local ablation. At more developed stages, only chemoembolization (for intermediate HCC) and sorafenib (for advanced HCC) have shown survival benefits. There are major unmet needs in HCC management that might be addressed through the discovery of new therapies and their combinations for use in the adjuvant setting and for intermediate- and advanced-stage disease. Moreover, biomarkers for therapy stratification, patient-tailored strategies targeting driver mutations and/or activating signalling cascades, and validated measurements of quality of life are needed. Recent failures in the testing of systemic drugs for intermediate and advanced stages have indicated a need to refine trial designs and to define novel approaches.
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Affiliation(s)
- Josep M Llovet
- Liver Cancer Program, Division of Liver Diseases and RM Transplant Institute, Tisch Cancer Institute, Department of Medicine, Icahn School of Medicine at Mount Sinai, Madison Avenue 1425, 11F-70, Box 1123, New York, New York 10029, USA.,Liver Cancer Translational Research Laboratory, Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, IDIBAPS - Hospital Clinic, CIBERehd, University of Barcelona, Catalonia, Spain.,Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Catalonia, Spain
| | - Jessica Zucman-Rossi
- INSERM, UMR-1162, Génomique Fonctionnelle des Tumeurs Solides, Equipe Labellisée Ligue Contre le Cancer, Institut Universitaire d'Haematologie, Paris, France.,Université Paris Descartes, Labex Immuno-Oncology, Sorbonne Paris Cité, Faculté de Médecine, Paris, France.,Université Paris 13, Sorbonne Paris Cité, Unité de Formation et de Recherche Santé, Médecine, Biologie Humaine, Bobigny, France.,Université Paris Diderot, Paris, France
| | - Eli Pikarsky
- Lautenberg Center for Immunology and Cancer Research and Department of Pathology, Hebrew University Hadassah-Medical School, Jerusalem, Israel
| | - Bruno Sangro
- Liver Unit, Clínica Universidad de Navarra, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra (IDISNA) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Pamplona, Spain
| | - Myron Schwartz
- Liver Cancer Program, Division of Liver Diseases and RM Transplant Institute, Tisch Cancer Institute, Department of Medicine, Icahn School of Medicine at Mount Sinai, Madison Avenue 1425, 11F-70, Box 1123, New York, New York 10029, USA
| | - Morris Sherman
- Department of Gastroenterology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gregory Gores
- Mayo Clinic, Mayo College of Medicine, Rochester, Minnesota, USA
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Bruix J, Reig M, Sherman M. Evidence-Based Diagnosis, Staging, and Treatment of Patients With Hepatocellular Carcinoma. Gastroenterology 2016; 150:835-53. [PMID: 26795574 DOI: 10.1053/j.gastro.2015.12.041] [Citation(s) in RCA: 1196] [Impact Index Per Article: 149.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 12/09/2015] [Accepted: 12/16/2015] [Indexed: 02/07/2023]
Abstract
Evidence-based management of patients with hepatocellular carcinoma (HCC) is key to their optimal care. For individuals at risk for HCC, surveillance usually involves ultrasonography (there is controversy over use of biomarkers). A diagnosis of HCC is made based on findings from biopsy or imaging analyses. Molecular markers are not used in diagnosis or determination of prognosis and treatment for patients. The Barcelona Clinic Liver Cancer algorithm is the most widely used staging system. Patients with single liver tumors or as many as 3 nodules ≤3 cm are classified as having very early or early-stage cancer and benefit from resection, transplantation, or ablation. Those with a greater tumor burden, confined to the liver, and who are free of symptoms are considered to have intermediate-stage cancer and can benefit from chemoembolization if they still have preserved liver function. Those with symptoms of HCC and/or vascular invasion and/or extrahepatic cancer are considered to have advanced-stage cancer and could benefit from treatment with the kinase inhibitor sorafenib. Patients with end-stage HCC have advanced liver disease that is not suitable for transplantation and/or have intense symptoms. Studies now aim to identify molecular markers and imaging techniques that can detect patients with HCC at earlier stages and better predict their survival time and response to treatment.
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Affiliation(s)
- Jordi Bruix
- Barcelona Clinic Liver Cancer Group, Liver Unit, Hospital Clinic, IDIBAPS, University of Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.
| | - Maria Reig
- Barcelona Clinic Liver Cancer Group, Liver Unit, Hospital Clinic, IDIBAPS, University of Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Morris Sherman
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Kuo MJ, Chen HH, Chen CL, Fann JCY, Chen SLS, Chiu SYH, Lin YM, Liao CS, Chang HC, Lin YS, Yen AMF. Cost-effectiveness analysis of population-based screening of hepatocellular carcinoma: Comparing ultrasonography with two-stage screening. World J Gastroenterol 2016; 22:3460-3470. [PMID: 27022228 PMCID: PMC4806204 DOI: 10.3748/wjg.v22.i12.3460] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/29/2015] [Accepted: 12/21/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the cost-effectiveness of two population-based hepatocellular carcinoma (HCC) screening programs, two-stage biomarker-ultrasound method and mass screening using abdominal ultrasonography (AUS).
METHODS: In this study, we applied a Markov decision model with a societal perspective and a lifetime horizon for the general population-based cohorts in an area with high HCC incidence, such as Taiwan. The accuracy of biomarkers and ultrasonography was estimated from published meta-analyses. The costs of surveillance, diagnosis, and treatment were based on a combination of published literature, Medicare payments, and medical expenditure at the National Taiwan University Hospital. The main outcome measure was cost per life-year gained with a 3% annual discount rate.
RESULTS: The results show that the mass screening using AUS was associated with an incremental cost-effectiveness ratio of USD39825 per life-year gained, whereas two-stage screening was associated with an incremental cost-effectiveness ratio of USD49733 per life-year gained, as compared with no screening. Screening programs with an initial screening age of 50 years old and biennial screening interval were the most cost-effective. These findings were sensitive to the costs of screening tools and the specificity of biomarker screening.
CONCLUSION: Mass screening using AUS is more cost effective than two-stage biomarker-ultrasound screening. The most optimal strategy is an initial screening age at 50 years old with a 2-year inter-screening interval.
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Crossan C, Tsochatzis EA, Longworth L, Gurusamy K, Davidson B, Rodríguez-Perálvarez M, Mantzoukis K, O'Brien J, Thalassinos E, Papastergiou V, Burroughs A. Cost-effectiveness of non-invasive methods for assessment and monitoring of liver fibrosis and cirrhosis in patients with chronic liver disease: systematic review and economic evaluation. Health Technol Assess 2015; 19:1-409, v-vi. [PMID: 25633908 DOI: 10.3310/hta19090] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver biopsy is the reference standard for diagnosing the extent of fibrosis in chronic liver disease; however, it is invasive, with the potential for serious complications. Alternatives to biopsy include non-invasive liver tests (NILTs); however, the cost-effectiveness of these needs to be established. OBJECTIVE To assess the diagnostic accuracy and cost-effectiveness of NILTs in patients with chronic liver disease. DATA SOURCES We searched various databases from 1998 to April 2012, recent conference proceedings and reference lists. METHODS We included studies that assessed the diagnostic accuracy of NILTs using liver biopsy as the reference standard. Diagnostic studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-analysis was conducted using the bivariate random-effects model with correlation between sensitivity and specificity (whenever possible). Decision models were used to evaluate the cost-effectiveness of the NILTs. Expected costs were estimated using a NHS perspective and health outcomes were measured as quality-adjusted life-years (QALYs). Markov models were developed to estimate long-term costs and QALYs following testing, and antiviral treatment where indicated, for chronic hepatitis B (HBV) and chronic hepatitis C (HCV). NILTs were compared with each other, sequential testing strategies, biopsy and strategies including no testing. For alcoholic liver disease (ALD), we assessed the cost-effectiveness of NILTs in the context of potentially increasing abstinence from alcohol. Owing to a lack of data and treatments specifically for fibrosis in patients with non-alcoholic fatty liver disease (NAFLD), the analysis was limited to an incremental cost per correct diagnosis. An analysis of NILTs to identify patients with cirrhosis for increased monitoring was also conducted. RESULTS Given a cost-effectiveness threshold of £20,000 per QALY, treating everyone with HCV without prior testing was cost-effective with an incremental cost-effectiveness ratio (ICER) of £9204. This was robust in most sensitivity analyses but sensitive to the extent of treatment benefit for patients with mild fibrosis. For HBV [hepatitis B e antigen (HBeAg)-negative)] this strategy had an ICER of £28,137, which was cost-effective only if the upper bound of the standard UK cost-effectiveness threshold range (£30,000) is acceptable. For HBeAg-positive disease, two NILTs applied sequentially (hyaluronic acid and magnetic resonance elastography) were cost-effective at a £20,000 threshold (ICER: £19,612); however, the results were highly uncertain, with several test strategies having similar expected outcomes and costs. For patients with ALD, liver biopsy was the cost-effective strategy, with an ICER of £822. LIMITATIONS A substantial number of tests had only one study from which diagnostic accuracy was derived; therefore, there is a high risk of bias. Most NILTs did not have validated cut-offs for diagnosis of specific fibrosis stages. The findings of the ALD model were dependent on assuptions about abstinence rates assumptions and the modelling approach for NAFLD was hindered by the lack of evidence on clinically effective treatments. CONCLUSIONS Treating everyone without NILTs is cost-effective for patients with HCV, but only for HBeAg-negative if the higher cost-effectiveness threshold is appropriate. For HBeAg-positive, two NILTs applied sequentially were cost-effective but highly uncertain. Further evidence for treatment effectiveness is required for ALD and NAFLD. STUDY REGISTRATION This study is registered as PROSPERO CRD42011001561. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Catriona Crossan
- Health Economics Research Group, Brunel University London, Uxbridge, UK
| | - Emmanuel A Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Louise Longworth
- Health Economics Research Group, Brunel University London, Uxbridge, UK
| | | | | | - Manuel Rodríguez-Perálvarez
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Konstantinos Mantzoukis
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Julia O'Brien
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Evangelos Thalassinos
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Vassilios Papastergiou
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Andrew Burroughs
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
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13
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Saab S, Alper T, Sernas E, Pruthi P, Alper MA, Sundaram V. Hospitalized Patients with Cirrhosis Should Be Screened for Clostridium difficile Colitis. Dig Dis Sci 2015; 60:3124-9. [PMID: 25986524 DOI: 10.1007/s10620-015-3707-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/06/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is an important public health problem in hospitalized patients. Patients with cirrhosis are particularly at risk of increased associated morbidity, mortality, and healthcare utilization from CDI. AIM The aim of this study was to assess the pharmacoeconomic impact of CDI screening on hospitalized patients with cirrhosis. METHODS A Markov model was used to compare costs and outcomes of two strategies for the screening of CDI. The first strategy consisted of screening all patients for CDI and treating if detected (screening). In the second strategy, only patients found to have symptomatic CDI were treated (no screening). The probability of underlying CDI prevalence, symptomatic CDI infection, and likelihood of recurrent infection were varied in a sensitivity analysis. The costs of antibiotics and hospitalization were also assessed. Differences in outcome were expressed in ratio of the total costs associated with screening to the total costs associated without screening. RESULTS The results of our model showed that screening for CDI was consistently associated with improved healthcare outcomes and decreased healthcare utilization across all variables in the one- and two-way sensitivity analyses. Using baseline assumptions, the costs associated with the no screening strategy were 3.54 times that of the screening strategy. Moreover, the mortality for symptomatic CDI was lower in the screening strategy than the no screening strategy. CONCLUSION The screening strategy results in less healthcare utilization and improved clinical outcomes. Screening for CDI measures favorably.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. .,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA. .,Pfleger Liver Institute, 200 Medical Plaza, Suite 214, Los Angeles, CA, 90095, USA.
| | - Theodore Alper
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Ernesto Sernas
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Paridhima Pruthi
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Vinay Sundaram
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Hassany SM, Moustafa EFA, Taher ME, Abdeltwab AA, Blum HE. Screening for hepatocellular carcinoma by Egyptian physicians. World J Gastrointest Oncol 2015; 7:161-171. [PMID: 26380060 PMCID: PMC4569594 DOI: 10.4251/wjgo.v7.i9.161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 06/02/2015] [Accepted: 08/21/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To assess the practice of Egyptian physicians in screening patients for hepatocellular carcinoma (HCC).
METHODS: The study included 154 physicians from all over Egypt caring for patients at risk for HCC. The study was based on a questionnaire with 20 items. Each questionnaire consisted of two parts: (1) personal information regarding the physician (name, age, specialty and type of health care setting); and (2) professional experience in the care of patients at risk for HCC development (screening, knowledge about the cause and natural course of liver diseases and HCC risk).
RESULTS: Sixty-eight percent of doctors with an MD degree, 48% of doctors with a master degree or a diploma and 40% of doctors with a Bachelor of Medicine, Bachelor of Surgery certificate considered the hepatitis C virus (HCV) genotype as risk factor for HCC development (P < 0.05). Ninety percent of physicians specialized in tropical medicine, internal medicine or gastroenterology and 67% of physicians in other specialties advise patients to undergo screening for HCV and hepatitis B virus infection as well as liver cirrhosis (P < 0.05). Eighty-six percent of doctors in University Hospitals and 69% of Ministry of Health (MOH) doctors consider HCV infection as the leading cause of HCC in Egypt (P < 0.05). Seventy-two percent of doctors with an MD degree, 55% of doctors with a master degree or a diploma, 56% of doctors with an MBBCH certificate, 74% of doctors in University Hospitals and 46% of MOH hospital doctors consider abdominal ultrasonography as the most important investigation in HCC screening (P < 0.05). Sixty-five percent of physicians in tropical medicine, internal medicine or gastroenterology and 37% of physicians in other specialties recommend as HCC screening interval of 3 mo (P < 0.05). Seventy-one percent of doctors with an MD degree, 50% of doctors with a master degree or diploma and 60% of doctors with an MBBCH certificate follow the same recommendation.
CONCLUSION: In Egypt, physicians specialized in tropical medicine, internal medicine or gastroenterology with an MD degree and working in a University Hospital are best informed about HCC.
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Abstract
The increasing incidence of hepatocellular carcinoma (HCC) has led to the need to identify patients at risk for HCC so that a program of screening can be undertaken. Screening for HCC has led to earlier diagnosis of tumors and thus has aided in initiating optimal medical treatment earlier in the disease course. Advances in radiological techniques and the identification of more accurate serum tests to diagnose HCC continue to be important areas of study and exploration. In particular, there have been efforts to develop new tumor markers to aid in the diagnosis of HCC and guide therapy of tumors.
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Affiliation(s)
- Heather N Simpson
- The University of Alabama School of Medicine, Department of Medicine, Division of Gastroenterology & Hepatology, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA
| | - Brendan M McGuire
- The University of Alabama School of Medicine, Department of Medicine, Division of Gastroenterology & Hepatology, Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, USA.
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16
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The cost of screening esophageal varices: traditional endoscopy versus computed tomography. J Comput Assist Tomogr 2015; 38:963-7. [PMID: 25229201 DOI: 10.1097/rct.0000000000000147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Under current guidelines, patients diagnosed with cirrhosis are to undergo initial and continued screening endoscopy for esophageal varices throughout the course of disease. Recent literature suggests that computed tomography (CT) of the abdomen is adequately sensitive for detecting grade 3 varices, those in need of immediate intervention. This study presents a cost comparison of traditional endoscopy versus CT of the abdomen. METHODS Using TreeAge Pro software, a budget impact cost model was created for a hypothetical managed care organization covering 1 million lives over a 10-year period. Incidence figures for cirrhosis and the progression of esophageal varices were applied to the patient population. National Medicare reimbursement costs were used to compare screening with traditional endoscopy versus CT. Costs utilizing screening with combined endoscopy and CT were also examined. RESULTS The results of comparing screening paradigms under a budget impact cost model results in an outcome measure termed "per-member, per-month" (PMPM) cost of implementing a new strategy. Computed tomography was the least expensive modality with an average 10-year cost per screened patient of $1097.30 and PMPM of $0.03. Endoscopy was the most expensive modality with an average 10-year cost per screened patient of $1464.89 and PMPM of $0.04. CONCLUSION Computed tomography has been shown to be sensitive in detecting esophageal varices and now less costly to implement in screening. The cost of esophageal rupture in endoscopy and the less costly risk of contrast reaction as well as radiation exposure in CT of the abdomen should be considered when developing a screening paradigm.
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17
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Management of hepatocellular carcinoma. J Cancer Res Clin Oncol 2014; 141:861-76. [DOI: 10.1007/s00432-014-1806-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 08/08/2014] [Indexed: 02/07/2023]
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Giannini EG, Cucchetti A, Erroi V, Garuti F, Odaldi F, Trevisani F. Surveillance for early diagnosis of hepatocellular carcinoma: How best to do it? World J Gastroenterol 2013; 19:8808-8821. [PMID: 24379604 PMCID: PMC3870532 DOI: 10.3748/wjg.v19.i47.8808] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 10/31/2013] [Accepted: 11/19/2013] [Indexed: 02/06/2023] Open
Abstract
Surveillance for hepatocellular carcinoma (HCC) is considered a standard of care for patients with chronic liver disease who are at risk of developing this malignancy. Several studies have shown that surveillance can improve the prognosis of patients diagnosed with HCC through an increased likelihood of application of curative or effective treatments. Repetition of liver ultrasonography (US) every 6 mo is the recommended surveillance program to detect early HCCs, and a positive US has to entrain a well-defined recall policy based on contrast-enhanced, dynamic radiological imaging or biopsy for the diagnosis of HCC. Although HCC fulfills the accepted criteria regarding cost-effective cancer screening and surveillance, the implementation of surveillance in clinical practice is defective and this has a negative impact on the cost-effectiveness of the procedure. Education of both physicians and patients is of paramount importance in order to improve the surveillance application and its benefits in patients at risk of HCC. The promotion of specific educational programs for practitioners, clinicians and patients is instrumental in order to expand the correct use of surveillance in clinical practice and eventually improve HCC prognosis.
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19
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Cost-effectiveness of liver cancer screening. Best Pract Res Clin Gastroenterol 2013; 27:961-72. [PMID: 24182614 DOI: 10.1016/j.bpg.2013.08.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 06/20/2013] [Accepted: 08/26/2013] [Indexed: 01/31/2023]
Abstract
Screening for primary liver cancer means surveillance for hepatocellular carcinoma (HCC), which is one of the most common cancers worldwide. Detection of HCC for curative treatment is increased by surveillance, but target population, optimal periodicity and cost-effectiveness aspects are still debated issues. The aim of surveillance is to obtain a reduction in HCC-related mortality and this is usually achieved through an early diagnosis that increases both applicability and cost-effectiveness of curative treatments. The aim of the present review is to analyse economic aspects of HCC surveillance. Articles that assessed cost-effectiveness of surveillance for HCC, published between 1996 and February 2013, were reviewed in order to verify the cost-effectiveness of surveillance, its optimal periodicity, the target population and the role of alternative surveillance strategies. International guidelines are currently based on the results of such cost-effectiveness analyses, highlighting the importance of the release of cost-effectiveness-guided guidelines for HCC management.
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Sherman M, Bruix J, Porayko M, Tran T. Screening for hepatocellular carcinoma: the rationale for the American Association for the Study of Liver Diseases recommendations. Hepatology 2012; 56:793-6. [PMID: 22689409 DOI: 10.1002/hep.25869] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 05/19/2012] [Accepted: 05/21/2012] [Indexed: 12/13/2022]
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Ruggeri M. Hepatocellular carcinoma: cost-effectiveness of screening. A systematic review. Risk Manag Healthc Policy 2012; 5:49-54. [PMID: 22826645 PMCID: PMC3401970 DOI: 10.2147/rmhp.s18677] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most common tumors worldwide. HCC is a potential target for cancer surveillance (or screening) as it occurs in well-defined, at-risk populations. Curative therapy is possible only for small tumors and screening strategy has been recommended by the US, Italian, and other international liver societies and is practiced widely, but its benefits are not clearly established. The objective of this study was to review the available evidence with respect to the cost-effectiveness of key technologies in the prevention HCC. The literature search was conducted with the support of PubMed. Firstly we selected articles by reading the abstracts. Secondly, we read the articles and the revision was further restricted, with the following as inclusion criteria: (1) full economic evaluation of HCC screening programs; (2) comparison between HCC techniques; (3) outcome measures expressed in terms of quality adjusted life years (QALY); (4) full text availability. The initial review of the literature yielded 346 articles. Of those, 288 were excluded at the first stage. Of those excluded, 108 did not meet the target, 106 did not present the cost analysis, 33 did not analyze the treatment of the disease, and in 41 the abstract was not available. Of the 58 included in the first step, seven examined the cost-effectiveness of different HCC screening techniques, seven investigated the cost-effectiveness of HCC screening versus no screening, and one looked at the cost-effectiveness of timing for HCC surveillance and monitoring, while 43 were about HBV vaccination and screening. We included only the seven articles examining the cost-effectiveness of different HCC screening techniques. In general, incidence is the key parameter which determines the cost-effectiveness of HCC screening. Discrepancies in the results exist when determining the type of technology to be used. Ultrasound (US) alone or in association with alpha fetoprotein (AFP) technology is likely to be the most cost effective and the use of computed tomography (CT) gives controversial results.
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Affiliation(s)
- Matteo Ruggeri
- Facoltà di Economia, Università Cattolica del Sacro Cuore - sede di Roma, Rome, Italy
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22
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL. A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma. Am J Surg 2011; 203:182-90. [PMID: 21679921 DOI: 10.1016/j.amjsurg.2011.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 02/10/2011] [Accepted: 02/10/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Ninety percent of patients with hepatocellular carcinoma (HCC) have cirrhosis. Bleeding esophageal varices (BEV) is a frequent complication of cirrhosis. Detection of HCC in cirrhotic patients with BEV has not been studied. METHODS Two hundred eleven unselected patients with cirrhosis and BEV were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup and treatment were initiated within 8 hours. Ninety-six percent had >10 years of follow-up. HCC screening involved serum α-fetoprotein (AFP) every 3 months, ultrasonography every 6 months, and selective computed tomography (CT). RESULTS HCC occurred in 15 patients, all incurable, a mean of 2.94 years after entry. They died a mean 1.33 years after discovery. Serial AFP and ultrasound examinations were unrevealing over a mean of 2.3 years. The mean model of end-stage liver disease score was 12.7 at entry and 17.4 at HCC diagnosis. CONCLUSIONS Long-term screening by AFP and ultrasound plus selective CT failed to detect HCC at a curable stage. The detection of HCC in cirrhotic patients with BEV remains a serious, unsolved problem. The use of CT for routine screening warrants consideration despite increased costs.
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California, San Diego, Medical Center, USA.
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23
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Fan ST, Poon RTP, Yeung C, Lam CM, Lo CM, Yuen WK, Ng KKC, Liu CL, Chan SC. Outcome after partial hepatectomy for hepatocellular cancer within the Milan criteria. Br J Surg 2011; 98:1292-300. [PMID: 21656513 DOI: 10.1002/bjs.7583] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2011] [Indexed: 01/04/2023]
Abstract
BACKGROUND There is a trend to offer liver transplantation to patients with hepatocellular carcinoma (HCC) with tumour status within the Milan criteria but with preserved liver function. This study aimed to evaluate the outcome of such patients following partial hepatectomy as primary treatment. METHODS A retrospective analysis was performed on all adult patients with HCC and tumour status within the Milan criteria undergoing partial hepatectomy at a single centre from 1995 to 2008. Their outcomes were compared with those of similar patients having right-lobe living donor liver transplantation (LDLT) as primary treatment. RESULTS A total of 408 patients with HCC were enrolled. Some 384 patients with a solitary tumour 5 cm or less in diameter had a better 5-year survival rate than 24 patients with oligonodular tumours (2-3 nodules, each 3 cm or less in size) (70·7 versus 46 per cent; P = 0·025). Multivariable analysis identified younger age (65 years or less), lack of postoperative complications, negative resection margin, absent microvascular invasion and non-cirrhotic liver as predictors of favourable overall survival. The 5-year survival rate of 287 younger patients with chronic liver disease and R0 hepatectomy was 72·8 per cent, comparable to that of 81 per cent in 50 similar patients treated by LDLT (P = 0·093). CONCLUSION Partial hepatectomy for patients with HCC and tumour status within the Milan criteria achieved a satisfactory 5-year survival rate, particularly in younger patients with solitary tumours and R0 hepatectomy. Patients with oligonodular tumours have a worse survival and might benefit from liver transplantation.
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Affiliation(s)
- S T Fan
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, 102 Pok Fu Lam Road, Hong Kong, China.
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Abstract
Active screening of patients at risk for HCC has led to the identification of early HCCs that are amenable to treatment with a high rate of cure. This requires high-quality ultrasound examinations at 6-month intervals. If widely applied, screening has the potential to substantially reduce the mortality from this disease. The application of the Barcelona Cancer of the Liver Clinic (BCLC) staging system should standardize assessment of prognosis and determination of the most effective treatments for each stage. With new molecular targeted agents coming, it is critical that studies are performed in patients stratified by stage into homogeneous groups. Because it is linked with therapy, the BCLC is ideally suited to this purpose.
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Affiliation(s)
- Morris Sherman
- Department of Medicine, University of Toronto, Toronto General Hospital, 585 University Avenue, Toronto, ON M5G 2N2, Canada.
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25
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Yang JD, Roberts LR. Epidemiology and management of hepatocellular carcinoma. Infect Dis Clin North Am 2011; 24:899-919, viii. [PMID: 20937457 DOI: 10.1016/j.idc.2010.07.004] [Citation(s) in RCA: 144] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hepatocellular carcinoma (HCC) is a major world health problem because of the high incidence and case fatality rate. In most patients, the diagnosis of HCC is made at an advanced stage, which limits the application of curative treatments. Most HCCs develop in patients with underlying chronic liver disease. Chronic viral hepatitis B and C are the major causes of liver cirrhosis and HCC. Recent improvements in treatment of viral hepatitis and in methods for surveillance and therapy for HCC have contributed to better survival of patients with HCC. This article reviews the epidemiology, cause, prevention, clinical manifestations, surveillance, diagnosis, and treatment approach for HCC.
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Affiliation(s)
- Ju Dong Yang
- Miles and Shirley Fiterman Center for Digestive Diseases, Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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26
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Abstract
Hepatocellular carcinoma (HCC) used to be considered a universally fatal disease. Today, however, we have tools to identify patients at risk for HCC with more accuracy. We are able to provide surveillance using ultrasonography that is sufficiently sensitive to detect small HCC lesions. Treatment of these lesions, whether by resection or by radiofrequency ablation, is highly effective. These advances mean that HCC is theoretically curable in the majority of patients, provided these tools are used. Microarray technology has been applied to the study of the genetic changes in HCC, and has defined several distinct genetic variants of this disease, as well as identifying gene signatures that predict poor outcome, and predict metastases. These techniques are now being used to identify new potential targets for therapy, and hold great promise for the future.
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Abstract
The consequences of chronic hepatitis B virus infection include hepatocellular carcinoma and liver cirrhosis. Effective antiviral therapy in patients with hepatitis B with advanced liver disease with viral suppression and sustained HBeAg seroconversion (where applicable) may abort hepatic decompensation, diminish hepatocellular risk, and reduce the risk of viral recurrence after transplantation. Overt hepatic decompensation is an indication for referral to a transplant center.
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Affiliation(s)
- Hui-Hui Tan
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Republic of Singapore.
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28
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Washburn K, Edwards E, Harper A, Freeman R. Hepatocellular carcinoma patients are advantaged in the current liver transplant allocation system. Am J Transplant 2010; 10:1643-8. [PMID: 20486906 DOI: 10.1111/j.1600-6143.2010.03127.x] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Patients with hepatocellular carcinoma (HCC) within Milan criteria receive priority on the liver transplant waiting list (WL) and compete with non-HCC patients. Dropout from the WL is an indirect measure of transplant access. Competing risks (CR) evaluation of dropout for HCC and non-HCC patients has not previously been reported. Patients listed between 16 March 2005 and 30 June 2008 were included. Probability of dropout was estimated using a CR technique as well as a Cox model for time to dropout. Overall, non-HCC patients had a higher dropout rate from the WL than HCC patients (p < 0.0001). This was reproducible throughout all regions. In Cox regression, tumor size, model for end-stage liver disease (MELD) score and alpha fetoprotein (AFP) were associated with increased dropout risk. Multivariable analysis with CR showed that MELD score and AFP, were most influential in predicting dropout for HCC patients. The index of concordance for predicting dropout with the CR was 0.70. HCC patients appear to be advantaged in the current allocation scheme based on lower dropout rates without regard to geography. A continuous score incorporating MELD, AFP and tumor size may help to prioritize HCC patients to better equate dropout rates with non-HCC patients and equalize access.
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Affiliation(s)
- K Washburn
- University of Texas Health Science Center, San Antonio, USA.
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29
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Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma. Hepatol Int 2010; 4:439-74. [PMID: 20827404 DOI: 10.1007/s12072-010-9165-7] [Citation(s) in RCA: 813] [Impact Index Per Article: 58.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 12/09/2009] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations. METHODS The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements. RESULTS Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.
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30
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Omata M, Lesmana LA, Tateishi R, Chen PJ, Lin SM, Yoshida H, Kudo M, Lee JM, Choi BI, Poon RTP, Shiina S, Cheng AL, Jia JD, Obi S, Han KH, Jafri W, Chow P, Lim SG, Chawla YK, Budihusodo U, Gani RA, Lesmana CR, Putranto TA, Liaw YF, Sarin SK. Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma. Hepatol Int 2010. [PMID: 20827404 DOI: 10.1007/s12072-011-9165-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations. METHODS The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements. RESULTS Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.
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31
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Andreana L, Isgrò G, Pleguezuelo M, Germani G, Burroughs AK. Surveillance and diagnosis of hepatocellular carcinoma in patients with cirrhosis. World J Hepatol 2009; 1:48-61. [PMID: 21160965 PMCID: PMC2998953 DOI: 10.4254/wjh.v1.i1.48] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 09/11/2009] [Accepted: 09/18/2009] [Indexed: 02/06/2023] Open
Abstract
Early identification of hepatocellular carcinoma (HCC) is more frequent because of surveillance programs for HCC worldwide. The optimal strategy of surveillance in cirrhosis is a current topical issue. In terms of diagnosis, recent advances in non-invasive imaging technology, including various techniques of harmonic ultrasound, new ultrasound contrast agents, multi-slice helical computed tomography and rapid high quality magnetic resonance, have all improved the accuracy of diagnosis. Consequently the role of liver biopsy in diagnosis of HCC has declined. The imaging diagnosis relies on the hallmark of arterial hypervascularity with portal venous washout. However, with recent advances in genomics and proteomics a great number of potential serum and tissue markers have been identified and are being developed as new candidate markers for both diagnosis and prognosis of hepatocellular carcinoma, and may increase the need for liver biopsy.
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Affiliation(s)
- Lorenzo Andreana
- Lorenzo Andreana, Graziella Isgrò, Maria Pleguezuelo, Giacomo Germani, Andrew K Burroughs, The Royal Free Sheila Sherlock Liver Center, Departement of Surgery, Royal Free Hospital, London, NW3 2QG, United Kingdom
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32
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Amarapurkar D, Han KH, Chan HLY, Ueno Y. Application of surveillance programs for hepatocellular carcinoma in the Asia-Pacific Region. J Gastroenterol Hepatol 2009; 24:955-61. [PMID: 19383082 DOI: 10.1111/j.1440-1746.2009.05805.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatocellular carcinoma (HCC) is a potential target for cancer surveillance (or screening) as it occurs in well-defined, at-risk populations and curative therapy is possible only for small tumors. Surveillance has been recommended by regional liver societies and is practiced widely, but its benefits are not clearly established. Hepatic ultrasonography with or without alpha fetoprotein (AFP) performed every 6 months is the preferred program. Surveillance of HCC has been well shown to detect small tumors for curative treatment, which may be translated to improved patient survival. However, most studies are limited by lead-time bias, length bias for early diagnosis of small HCC, different tumor growth rates and poor compliance with surveillance. Cost-effectiveness of surveillance programs depends on the rate of small HCC detected 'accidentally' (routine imaging) in a comparator group, annual incidence of HCC with various etiologies, patient age and the availability of liver transplantation. The incremental cost-effectiveness for 6-monthly AFP and ultrasound has been estimated from approximately $US 26,000-74,000/quality adjusted life years (QALY). All cirrhotic patients are therefore recommended for HCC surveillance unless the disease is too advanced for any curative treatment. As chronic hepatitis B can develop into HCC without going through liver cirrhosis, high-risk non-cirrhotic chronic hepatitis B patients are also recommended for HCC surveillance. In conclusion, HCC surveillance could be effective at reducing disease-specific mortality with acceptable cost-effectiveness among selected patient groups, provided it is a well-organized program.
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Abstract
Timely surveillance for varices and hepatocellular carcinoma, prophylaxis against spontaneous bacterial peritonitis (SBP) improve survival in patients awaiting transplantation. Early diagnosis of minimal or overt hepatic encephalopathy can delay life threatening complications, reduce need for hospitalization, and potentially improve survival pending liver transplantation.
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Affiliation(s)
- Priya Grewal
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, The Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1104, New York, NY 10029, USA.
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Hepatocellular Carcinoma in Keio Affiliated Hospitals — Diagnosis, Treatment, and Prognosis of this Disease —. Keio J Med 2009; 58:161-75. [DOI: 10.2302/kjm.58.161] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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35
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Andersson KL, Salomon JA, Chung RT, Goldie SJ. Cost effectiveness of alternative surveillance strategies for hepatocellular carcinoma in patients with cirrhosis. Clin Gastroenterol Hepatol 2008; 6:1418-24. [PMID: 18848905 PMCID: PMC4340842 DOI: 10.1016/j.cgh.2008.08.005] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Revised: 07/20/2008] [Accepted: 08/10/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The increasing incidence of hepatocellular carcinoma (HCC) in the United States has significant health and economic consequences. Ultrasound (US) surveillance is recommended for patients with cirrhosis because of their high risk of HCC and improving treatment outcomes for small tumors. We assessed the costs, clinical benefits, and cost effectiveness of US surveillance and alternative strategies for HCC in cirrhosis using a computer-based state transition model with parameters derived from available literature. METHODS Our model compared a policy of no surveillance with 6 surveillance strategies in cirrhotic patients ages 50 years and older in the United States: (1) annual US, (2) semiannual US, (3) semiannual US with alpha-fetoprotein, (4) annual computed tomography (CT), (5) semiannual CT, and (6) annual magnetic resonance imaging. The number of screening tests needed to detect one small HCC, cost per treated HCC, lifetime costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios were calculated. RESULTS Semiannual US surveillance for HCC in cirrhosis increased quality-adjusted life expectancy by 8.6 months on average, but extended it nearly 3.5 years in patients with small treated tumors. Semiannual US surveillance had an incremental cost-effectiveness ratio of $30,700 per quality-adjusted life year (QALY) gained, and was more cost effective than the alternative surveillance strategies using a threshold of $50,000 per QALY gained. The incremental cost-effectiveness ratios for the combined alpha-fetoprotein/US and annual CT strategies exceeded $50,000/QALY unless the sensitivity and specificity of US decreased to less than 65% and 60%, respectively. CONCLUSIONS Semiannual US surveillance for HCC in cirrhotic patients improves clinical outcomes at a reasonable cost.
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Affiliation(s)
| | | | - Raymond T. Chung
- Harvard Medical School and GI Unit, Massachusetts General Hospital
| | - Sue J. Goldie
- Program in Health Decision Science, Harvard School of Public Health
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Manzione L, Grimaldi AM, Romano R, Ferrara D, Dinota A. Hepatocarcinoma: from pathogenic mechanisms to target therapy. Oncol Rev 2008. [DOI: 10.1007/s12156-008-0077-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Paul SB, Sreenivas V, Gulati MS, Madan K, Gupta AK, Mukhopadhyay S, Acharya SK. Economic evaluation of a surveillance program of hepatocellular carcinoma (HCC) in India. Hepatol Int 2008; 2:231-6. [PMID: 19669309 PMCID: PMC2716843 DOI: 10.1007/s12072-008-9054-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2007] [Accepted: 01/23/2008] [Indexed: 10/22/2022]
Abstract
PURPOSE Surveillance of patients of cirrhosis of liver is practiced for early detection of HCC. No data from any developing country on cost-effectiveness of such a program are available. METHODS Economic evaluation of HCC surveillance was embedded in a prospective study undertaken to estimate the incidence of HCC in 194 cirrhotics. The protocol consisted of 6 monthly abdominal ultrasound (US) and serum alphafetoprotein (AFP) estimation, and yearly triple phase CT. Cost was estimated from the hospital and patient perspectives. Cost-effectiveness ratios for detecting a case of HCC were estimated. Modeling was done to estimate cost effectiveness with different combinations of diagnostic tests. RESULTS Cost-effectiveness ratios of HCC surveillance program per HCC case detected were estimated as US$ 280 from the hospital perspective. From patient perspective, these were US$ 9,965 for outstation and US$ 2,808 for local patients. Cost-effectiveness ratio for direct medical cost per case of HCC detected by 6 monthly US and AFP, the EASL protocol, was estimated to be US$ 1,510 in the private sector. CONCLUSION The cost of HCC surveillance program is exorbitant for India (gross national income per capita US$ 620) and possibly other low/middle income countries.
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Affiliation(s)
- Shashi Bala Paul
- Department of Radio-diagnosis, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Vishnubhatla Sreenivas
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Manpreet Singh Gulati
- Department of Radio-diagnosis, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Kaushal Madan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Arun Kumar Gupta
- Department of Radio-diagnosis, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Sima Mukhopadhyay
- Department of Radio-diagnosis, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Subrat Kumar Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029 India
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El-Serag HB, Marrero JA, Rudolph L, Reddy KR. Diagnosis and treatment of hepatocellular carcinoma. Gastroenterology 2008; 134:1752-63. [PMID: 18471552 DOI: 10.1053/j.gastro.2008.02.090] [Citation(s) in RCA: 795] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Revised: 02/05/2008] [Accepted: 02/25/2008] [Indexed: 02/08/2023]
Abstract
The diagnosis and treatment of hepatocellular carcinoma (HCC) have witnessed major changes over the past decade. Until the early 1990s, HCC was a relatively rare malignancy, typically diagnosed at an advanced stage in a symptomatic patient, and there were no known effective palliative or therapeutic options. However, the rising incidence of HCC in several regions around the world coupled with emerging evidence for efficacy of screening in high-risk patients, liver transplantation as a curative option in select patients, ability to make definitive diagnosis using high-resolution imaging of the liver, less dependency on obtaining tissue diagnosis, and proven efficacy of transarterial chemoembolization and sorafenib as palliative therapy have improved the outlook for HCC patients. In this article, we present a summary of the most recent information on screening, diagnosis, staging, and different treatment modalities of HCC, as well as our recommended management approach.
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Affiliation(s)
- Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas 77030, USA.
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Abstract
It is becoming increasingly evident that children, like adults, with chronic viral or metabolic liver diseases are at risk for the development of hepatocarcinoma. The aims of this article are to review the risk factors for hepatocarcinoma in chronic viral or metabolic liver disease, outline potential pathogenic mechanisms of hepatocarcinoma, and describe surveillance strategies, clinical evaluation, and management of hepatocarcinoma in children.
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Wong G, Chapman JR, Craig JC. Cancer screening in renal transplant recipients: what is the evidence? Clin J Am Soc Nephrol 2008; 3 Suppl 2:S87-S100. [PMID: 18309007 PMCID: PMC3152279 DOI: 10.2215/cjn.03320807] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Increased cancer risk is well established in the renal transplant population. Little, however, is known about the benefits and harms of cancer screening, treatment effectiveness, and the overall cancer prognosis in renal transplant recipients. In this study, we critically appraised guidelines for cancer screening in the renal transplant and general populations using standard criteria for an evidence-based screening program. Guidelines were included when they were applied to adult participants, had objectives specific to cancer screening, and were written in English. Recommendations for breast and colorectal cancer screening in the general population were supported by evidence of cancer-specific mortality benefits from randomized, controlled trials of cancer screening. Convincing evidence from observational studies had demonstrated population cervical cancer screening was effective, also, test performance of mammography, faecal occult blood testing, and Pap smear were accurate. Population breast, colorectal, and cervical cancer screening also appeared to be good value for money in the general population. On the contrary, recommendations for cancer screening in renal transplant recipients were entirely extrapolated from data in the general population. Studies in the general population have led to the development of cancer screening guidelines in transplant recipients. Because of increased cancer risk, differences in diagnostic test performance, competing risks for deaths from causes such as cardiovascular disease and reduced overall life expectancies, validity of their recommendations are uncertain. Future studies are needed to address these issues to provide the necessary evidence for informed decision-making.
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Affiliation(s)
- Germaine Wong
- Centre for Kidney Research, Children's Hospital at Westmead, Locked bag 4001, Westmead, NSW 2145, Australia.
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Bremner KE, Bayoumi AM, Sherman M, Krahn MD. Management of solitary 1 cm to 2 cm liver nodules in patients with compensated cirrhosis: a decision analysis. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 21:491-500. [PMID: 17703248 PMCID: PMC2657973 DOI: 10.1155/2007/182383] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Current guidelines, based on expert opinion, recommend that suspected 1 cm to 2 cm hepatocellular carcinoma (HCC) detected on screening be biopsied and, if positive, treated (eg, resection or transplantation). Alternative strategies are immediate treatment or observation until disease progression occurs. METHODS A Markov decision model was developed that compared three management strategies - immediate resection, biopsy and resection if positive, and ultrasound surveillance every three months until disease progression - for a single 1 cm to 2 cm liver nodule suspicious for HCC following ultrasound screening and computed tomography confirmation. The cohort included 55-year-old patients with compensated cirrhosis and no significant comorbidities. The model used in the present study incorporated the probabilities of false-positive and false-negative results, needle-track seeding, HCC recurrence, cirrhosis progression and death. The quality-adjusted life expectancy (LE) and the unadjusted LE were evaluated and the model's strength was assessed with sensitivity analyses. RESULTS In the base case analysis, biopsy, resection and surveillance yielded an unadjusted LE of 60.5, 59.7 and 56.6 months, respectively, and a quality-adjusted LE of 46.6, 45.6 and 43.8 months, respectively. In probabilistic sensitivity analyses, biopsy was the preferred strategy 69.5% of the time, resection 30.5% of the time and surveillance never. Resection was the optimal decision if the sensitivity of biopsy was very low (less than 0.45) or if the accuracy of the imaging tests resulted in a high percentage of HCC-positive patients (greater than 76%) in the screened cohort, as with expert interpretation of triphasic computed tomography. CONCLUSIONS The present model suggests that biopsy is the preferred management strategy for these patients. When postimaging probability of HCC is high or pathology expertise is lacking, resection is the best alternative. Surveillance is never the optimal strategy.
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Affiliation(s)
- Karen E Bremner
- Toronto General Research Institute, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
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Abstract
The Model for End-stage Liver Disease (MELD) was initially created to predict survival in patients with complications of portal hypertension undergoing elective placement of transjugular intrahepatic portosystemic shunts. The MELD which uses only objective variables was validated subsequently as an accurate predictor of survival among different populations of patients with advanced liver disease. The major use of the MELD score has been in allocation of organs for liver transplantation. However, the MELD score has also been shown to predict survival in patients with cirrhosis who have infections, variceal bleeding, as well as in patients with fulminant hepatic failure and alcoholic hepatitis. MELD may be used in selection of patients for surgery other than liver transplantation and in determining optimal treatment for patients with hepatocellular carcinoma who are not candidates for liver transplantation. Despite the many advantages of the MELD score, there are approximately 15%-20% of patients whose survival cannot be accurately predicted by the MELD score. It is possible that the addition of variables that are better determinants of liver and renal function may improve the predictive accuracy of the model. Efforts at further refinement and validation of the MELD score will continue.
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Affiliation(s)
- Patrick S Kamath
- Advanced Liver Disease Study Group, Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Kim YJ, Raman SS, Yu NC, To'o KJ, Jutabha R, Lu DSK. Esophageal varices in cirrhotic patients: evaluation with liver CT. AJR Am J Roentgenol 2007; 188:139-44. [PMID: 17179356 DOI: 10.2214/ajr.05.1737] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the performance of routine helical liver CT in the detection and grading of esophageal varices in cirrhotic patients. MATERIALS AND METHODS A total of 67 consecutive cirrhotic patients who underwent both upper endoscopy and helical liver CT within a 4-week interval were evaluated. The CT protocol included unenhanced, arterial, and portal phases with a collimation of 7-7.5 mm. Two blinded abdominal imagers (6 and 7 years' experience) retrospectively interpreted all CT images to detect the presence of esophageal varices on a 5-point confidence scale and measure the largest varix identified. Receiver operating characteristic (ROC) curve analysis was performed, and the correlation between CT measurements and endoscopic grading, the reference standard, was assessed. RESULTS The variceal detection rates for the observers was 92% (11/12) and 92% (11/12) for large (i.e., clinically significant) varices, 53% (16/30) and 60% (18/30) for small varices, and 64% (27/42) and 69% (29/42) for all varices. The area under the ROC curve for the detection of esophageal varices of any size was 0.77 (observer 1) and 0.80 (observer 2). CT variceal grading showed a strong correlation with endoscopic grading for both observers (p < or = 0.001). Using a variceal diameter threshold of 3 mm on CT, sensitivity, specificity, and accuracy for distinguishing large esophageal varices from small or no varices were 92% (11/12), 84% (46/55), and 85% (57/67), respectively, for both observers. CONCLUSION Liver CT is useful for the detection and grading of esophageal varices. A diameter of 3 mm may be an appropriate screening threshold for large clinically significant varices.
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Affiliation(s)
- Young Jun Kim
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., Los Angeles, CA 90095-1721, USA
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Trinchet JC, Ganne-Carrié N. [Should we screen for hepatocellular carcinoma?]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2006; 30:880-6. [PMID: 16885873 DOI: 10.1016/s0399-8320(06)73336-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Jean-Claude Trinchet
- Hépato-Gastroentérologie, Hôpital Jean Verdier, Assistance Publique-Hôpitaux de Paris, UFR SMBH-Université Paris 13, 93143 Bondy Cedex.
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Saab S, Nguyen S, Ibrahim A, Vierling JM, Tong MJ. Management of patients with cirrhosis in Southern California: results of a practitioner survey. J Clin Gastroenterol 2006; 40:156-61. [PMID: 16394878 DOI: 10.1097/01.mcg.0000196189.65167.53] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Cirrhosis is an important medical and public health concern. A paucity of data exists on how patients with cirrhosis are managed. Our aims were to determine how cirrhosis is managed and whether current management practices follow established recommendations. METHODS A questionnaire was mailed to Southern California Society of Gastroenterology members. Most had practiced for more than 15 years (67%) in a private practice setting (69%). Proportions of physicians who followed established guidelines versus those who had not were compared using chi test. RESULTS Hepatitis A, hepatitis B, influenza, and pneumococcus vaccinations were recommended by most respondents. Ninety-one percent of respondents routinely screened patients for hepatocellular carcinoma. A significantly greater proportion of respondents screened for hepatocellular carcinoma using either alpha-fetoprotein or ultrasound every 6 months (P < 0.05). Seventy-six percent recommended antibiotic prophylaxis in patients with prior spontaneous bacterial peritonitis, whereas less than half recommended prophylaxis in patients with ascitic protein fluid <1 g/dL, current variceal bleed, and those on the liver transplant list. Sixty-seven percent of respondents performed screening esophagogastroduodenoscopy upon diagnosis of cirrhosis. Most respondents did not recommend repeating endoscopy in 1 to 2 years if a patient was found to have small varices (P < 0.05), and would repeat an endoscopy if large varices were found (P < 0.05). CONCLUSION The management of patients with cirrhosis in the community varied and did not always conform to established guidelines. These results should be confirmed in a larger group of physicians, and the rationales for physicians accepting or rejecting established guidelines should be further assessed.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA.
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Affiliation(s)
- Jordi Bruix
- BCLC Group. Liver Unit. Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.
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Kim WR. The use of decision analytic models to inform clinical decision making in the management of hepatocellular carcinoma. Clin Liver Dis 2005; 9:225-34. [PMID: 15831270 DOI: 10.1016/j.cld.2004.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Decision analysis helps evaluate competing strategies under conditions of uncertainty in a wide variety of clinical settings. Despite some limitations, decision trees and Markov models remain essential tools for medical decision analysts. These techniques allow comparison of competing management strategies in a quantitative fashion. Sensitivity analysis is an important feature of decision analytic models that identify important factors that affect the outcome of decisions under considerations. Judiciously used, decision analytic models allow a quantitative evaluation of existing data as they relate to strategies ranging from optimizing clinical management at the patient level to allocating health care resources at the societal level.
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Affiliation(s)
- W Ray Kim
- Mayo Clinic College of Medicine, Division of Gastroenterology, Rochester, MN 55905, USA.
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Abstract
There is currently no evidence that screening patients at risk for hepatocellular carcinoma reduces mortality from the disease. Nonetheless, screening is widely practiced. Screening is a process that includes selecting patients, applying screening tests, deciding on recall policies, and subsequently proving or disproving the presence of cancer. The literature on screening for hepatocellular carcinoma is confusing at best, and does not adequately consider the many biases that result from uncontrolled and retrospective studies. Nonetheless, screening can be justified because it is likely that mortality is decreased by adequate treatment of small cancers, particularly in the era of liver transplantation. False-positive screening test results are common. Once an abnormal screening result is obtained there is little guidance from the literature as to how patients should be investigated further, nor about how to determine whether the screening test result was a false-positive. This should at minimum include short interval follow-up with CT scans and MRI's.
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Affiliation(s)
- Morris Sherman
- University of Toronto and Toronto General Hospital, 200 Elizabeth Street, Toronto, Ont., Canada M5G 2C4.
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