Surveillance for hepatocellular carcinoma at the community level: Easier said than done.

Surveillance for hepatocellular carcinoma (HCC) in high-risk patients with semiannual ultrasound examinations is advocated by all international guidelines. However, as long as the identification of the population to be screened and the surveillance programs are not well implemented, the real-life impact of HCC surveillance in reducing mortality for HCC cannot be known. We propose a new approach that promotes the identification of cirrhotic patients by primary care physicians (PCPs) and referral of patients to the hepatologist for surveillance. Surveillance should be incorporated, when feasible, in a hub and spoke model of comprehensive hepatology care. Training PCPs to identify cirrhotic patients and performing surveillance in a subspecialist setting are equally important to improve the effectiveness of real-life surveillance and to decrease HCC mortality over time.

A training program for primary care physicians improves the effectiveness of ultrasound surveillance of hepatocellular carcinoma.

BACKGROUND AND AIMS: Cirrhosis is the main risk factor of hepatocellular carcinoma (HCC), but only a minority of cirrhotic patients are referred to the hepatologist by primary care physicians (PCP) and receive regular ultrasound surveillance. The aim of this study was to determine whether a training program targeted to PCP could enhance the effectiveness of surveillance in a real-life setting. PATIENTS AND METHODS: A total of 120 PCP in an Italian area with a high incidence of HCC were trained to identify cirrhotic patients, to refer them to the Hepatology Centers of the area, and to start regular ultrasound surveillance. Clinical characteristics, outcome of treatments, and survival of 190 consecutive HCC patients in the same centers after training were compared with 244 HCC referred from the same area before training, and to 232 HCC referred by untrained PCP from other areas. RESULTS: Trained PCP referred significantly more HCC patients detected under surveillance and at an early stage (Barcelona Clinic Liver Cancer-A), suitable for radical treatments. In the intervention area, the 3 and 5-year survival of HCC patients increased after training from 35 to 48% and from 20 to 40%, respectively (P<0.05). In contrast, survival was unchanged in the other areas. At multivariate analysis, independent predictors adversely affecting survival were Child-Pugh B-C, α-fetoprotein more than 10 ng/dl, nonviral etiology, intermediate/advanced Barcelona Clinic Liver Cancer stage, and referral by an untrained PCP. CONCLUSION: Specific training of PCP aimed at the identification and referral of cirrhotic patients efficiently improves HCC survival.

Screening in liver disease.

A disease is suitable for screening if it is common, if the target population can be identified and reached and if both a good screening test and an effective therapy are available. Of the most common liver diseases only viral hepatitis and genetic hemochromatosis partially satisfy these conditions. Hepatitis C is common, the screening test is good and the therapy eliminates the virus in half of the cases, but problems arise in the definition of the target population. In fact generalized population screening is not endorsed by international guidelines, although some recommend screening immigrants from high prevalence countries. Opportunistic screening (case finding) of individuals with classic risk factors, such as transfusion before 1992 and drug addiction, is the most frequently used strategy, but there is disagreement whether prison inmates, individuals with a history of promiscuous or traumatic sex and health care workers should be screened. In a real practice setting the performance of opportunistic screening by general practitioners is low but can be ameliorated by training programs. Screening targeted to segments of the population or mass campaigns are expensive and therefore interventions should be aimed to improve opportunistic screening and the detection skills of general practitioners. Regarding genetic hemochromatosis there is insufficient evidence for population screening, but individual physicians can decide to screen racial groups with a high prevalence of the disease, such as people in early middle age and of northern European origin. In the other cases opportunistic screening of high risk individuals should be performed, with a high level of suspicion in case of unexplained liver disease, diabetes, juvenile artropathy, sexual dysfunction and skin pigmentation.