Screening in Australia
Disease
In Western countries, hepatocellular carcinoma develops nearly exclusively in patients with cirrhosis. In these patients it has the potential to shorten life expectancy significantly. Thus, for this particular patient group it is an important disease. If the disease is detected early (ie. as a single nodule) it is readily treatable by partial hepatectomy.
Test
Recommended screening tests include alpha-fetoprotein and ultrasound.
Alpha-fetoprotein
This is commonly elevated in hepatocellular carcinoma. It is unfortunately plagued by poor sensitivity in trials (sensitivity about 50%), and sensitivity is about 80-90%. Alone, it has not been shown to improve overall survival.
Ultrasound
Ultrasound is the most commonly used imaging test in screening. It also shows no survival advantage when used alone, but has higher sensitivity and specificity than AFP alone (70% and 90%).
Other imaging modalities
CT or MRI are under evaluation. They have higher sensitivity (80%) but also much higher costs than ultrasound.
Combination of tests
AFP and ultrasound are currently recommended by the European Association for Study of the Liver. Survival advantages have been seen in third world countries.
Treatment
Early treatment is not always possible in hepatocellular carcinoma due to poor liver health. Australia has an organ donor registry and liver transplantation is possible, but not always effective. Early stage tumours can also be amenable to local treatments such as percutaneous radiofrequency ablation or ethanol injection.
Screening Program
There is no randomised evidence showing a survival advantage for screening in typical Western populations. Most patients with established cirrhosis are still screened every 6 months with AFP and ultrasound as recommended by the European Association for the Study of the Liver. This is done through specialised liver clinics in tertiary hospitals.
Screening in Other Countries
Worldwide guidelines suggest screening in high risk patients:
- Chronic Hepatitis B Infection:
- African men above the age of 20
- Asian men above the age of 40
- African/Asian women above the age of 50
- In all with cirrhosis
- All patients with cirrhosis due to:
- Hepatitis C infection
- Alcoholism
- Genetic causes (eg. haemochromotosis, alpha-1-antitrypsin deficiency)
Screening is only suitable when the country has the resources to offer appropriate treatment which is often not the case in the third world.
