Effectiveness of surveillance for hepatocellular carcinoma in clinical practice: A United States cohort

Background & Aims: The effectiveness of surveillance for hepatocellular carcinoma (HCC) in reducing cancer related mortality among patients with cirrhosis is largely unknown. The objective of this study was to study the effectiveness of HCC surveillance in the national Veterans Administration (VA) clinical practice. Methods: We conducted a retrospective cohort study of patients with HCC during 2005-2010 by reviewing patients' medical records to determine receipt of HCC surveillance in the 2 years prior to HCC diagnosis. We determined association of HCC surveillance with overall mortality adjusting for age, risk factors, model for end-stage liver disease (MELD) score, comorbidity index, alpha-fetoprotein levels, healthcare utilization, Barcelona Clinic Liver Cancer (BCLC) stage, and treatment. We accounted for lead and length time biases. Results: Of 887 patients with HCC, only 412 (46.5%) received any surveillance prior to HCC diagnosis. Patients who received surveillance were significantly more likely to have early stage disease HCC (BCLC stage 0/A 27.2% vs. 11.6%) and receive potentially curative (20.9% vs. 11.6%) or palliative (59.2% vs. 45.5%) treatments compared to those without HCC surveillance. Receipt of HCC surveillance was associated with 38% reduction in mortality risk (unadjusted hazard ratios (HR) 0.62, 95% confidence intervals (CI) 0.54-0.71) that declined to 20% (HR 0.80, 95% CI 0.69-0.94) after adjusting for HCC stage and treatment, compared to those without HCC surveillance. Conclusions: Among patients with HCC, pre-diagnosis HCC surveillance is associated with a significant 38% reduction in overall mortality. The reduction in mortality risk with surveillance is mediated via stage migration and receipt of HCC specific treatment. Lay summary: Surveillance for liver cancer leads to earlier detection of cancer and increases chances of getting curative treatment. This ultimately leads to increased longevity in patients with liver cancer. (C) 2016 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.