HCC Global Screening Programs for At-Risk Populations

Peter Galle, MD: In Europe we basically follow the recommendations of the European Association for the Study of the Liver, and they have been recently updated, in 2018. Here we recommend the performance of ultrasound twice a year, every 6 months. This is an interesting aspect in terms of differences worldwide. In Asia, the addition of alpha-fetoprotein assessment is more or less mandatory. In the United States it’s optional, and in Europe it’s not recommended, so there are discrepancies as well to both. In the real world, I would say most physicians indeed include alpha-fetoprotein testing to the armamentarium and add it to ultrasound.

The problem is that if we watch what results we get, then we realize we, in most countries in Europe, detect early-stage cancer in only about 25% or so, telling us that we are not adhering very well to screening programs. Otherwise we would be much better. The best example here is Japan. They are very successful. They detect the vast majority of their patients in early stage and demonstrate that screening programs can be effective. But in Europe overall, it’s safe to say that in many countries patients are just neglected. Cirrhotics are not regularly screened, although the recommendations are very clear.

Minsig Choi, MD: What are the typical current screening procedures in the United States for liver cancer? In patients who are high risk, these are people with hepatitis C and cirrhosis and people with chronic hepatitis B infection are at risk of developing liver cancer. In those high-risk patients, what we usually recommend is doing ultrasound every 6 months to assess fine and liver nodules or liver cancer. We also add alpha-fetoprotein as 1 of the tumor markers in assessing those patients.

Now we have to understand that ultrasound is operator dependent. Therefore, in institutions where you cannot have very reliable ultrasound technicians and you can’t do the procedure in a good way, we recommend doing either a CT [computed tomography] scan or MRI [magnetic resonance imaging].

Masatoshi Kudo, MD, PhD: At-risk populations in Asia are those with hepatitis B virus cirrhosis, and it occurs mostly in Japan. But I see it as it cirrhosis and at risk for HCC [hepatocellular carcinoma]. Screening procedure in Asia mostly using ultrasound and AP [arterial perfusion] every 6 months. But in Japan, more intensive surveillance is performed, like ultrasound plus 3 tumor markers—AP plus APL2 and APL3 [arterial pseudolesions]—are measured every 3 to 4 months. Plus, for cirrhotic patients, every 6 to 12 months, an EOB [ethoxybenzyl] MRI is recommended. So it’s more extensively performed in Japan.

Transcript Edited for Clarity