Hepatocellular carcinoma surveillance with ultrasound-cost-effectiveness, high-risk populations, uptake

Machine learning models for predicting hepatocellular carcinoma development in patients with chronic viral hepatitis B infection

Background

Chronic hepatitis B (CHB) infection is the major risk factor for hepatocellular carcinoma (HCC).

Objective

To develop machine-learning models for predicting an individual risk of HCC development in CHB-infected patients.

Methods

Machine learning models were constructed using features from follow-up visits of CHB patients to predict the diagnosis of HCC development within 6 months after each index follow-up. We developed 4 model variants using all features, with alpha fetoprotein (AFP) (AF A ) and without AFP (AFN ); and selected features, with AFP (SF A ) and without AFP (SFN ). Performance was evaluated using 10-fold cross-validation on a derivation cohort and further validated on an independent cohort.

Results

In the derivation cohort of 2,382 patients, of whom 117 developed HCC, AFA achieved higher sensitivity (0.634, 95% confidence interval [CI]: 0.559-0.708) and specificity (0.836; 0.830-0.842) than AF N (sensitivity 0.553; 0.476-0.630 and specificity 0.786; 0.779-0.792). SFA also achieved higher sensitivity (0.683; 0.611-0.755 vs. 0.658; 0.585-0.732) and specificity (0.756; 0.749-0.763 vs. 0.744; 0.737-0.751) than SFN . Performance of SFA and SFN were tested in another cohort of 162 patients in which 57 patients developed HCC. SFA achieved sensitivity and specificity of 0.634 (0.522-0.746) and 0.657 (0.615-0.699), while sensitivity and specificity of SFN were 0.690 (0.583-0.798) and 0.651 (0.609-0.693), respectively.

Conclusion

The machine learning models demonstrate good performance for predicting short-term risk for HCC development and may potentially be used for tailoring surveillance interval for CHB patients.

Improved Effectiveness of Combined Screening for Multiple Cancers: A Government-Organized Population-Based Study in China

OBJECTIVE

The purpose of this study was to analyze the effectiveness of the Cancer Screening Program in Urban China (CanSPUC) in Hebei Province, 2016-2023.

METHODS

A questionnaire for risk factors of lung, breast, upper gastrointestinal, liver, and colorectal cancers was administered to urban residents aged 40-74 years in five cities to assess their cancer risk. High-risk participants were invited for screening and classified into five groups on the basis of the number of cancer types that were assessed to be high risk. The participation and positive outcome rates were analyzed. The incidence and the mortality of five types of cancer and all-cause mortality of the screened and nonscreened participants were calculated via inverse probability weighting.

RESULTS

A total of 237,975 eligible participants were enrolled in our study and 118,339 participants (49.94%) were assessed to be at high risk for one or more of the five cancer types. The number of screenings performed was 103,824, with a screening participation rate of 40.49%. Among the 57,315 screening participants, 9077 (15.84%) had positive cancer diagnoses and 871 (1.52%) were diagnosed with suspected cancer. Compared with the participants at high risk for a single cancer type, the participation and positive outcome rate increased by 45% and 71.5% in the participants at high risk for multiple cancer types. Compared with the non-screened participants, the screened participants had a 27.0% decrease in mortality due to the five types of cancer and a 45.8% decrease in all-cause mortality.

CONCLUSION

A combined screening program for multiple cancers could increase participation and positive outcome rates. It could also decrease the five types of cancer mortality and all-cause mortality. Our findings highlight the effectiveness of combined screening for multiple cancers with limited health care resources, and may provide foundational evidence for the feasibility of conducting combined screening programs.

Risk-stratified hepatocellular carcinoma screening according to the degree of obesity and progression to cirrhosis for diabetic patients with metabolic dysfunction-associated steatotic liver disease (MASLD) in Japan: a cost-effectiveness study

OBJECTIVE

To evaluate the cost-effectiveness of risk-stratified hepatocellular carcinoma (HCC) screening in diabetic patients with metabolic dysfunction-associated steatotic liver disease (MASLD).

DESIGN

A state-transition model from a healthcare payer perspective on a lifetime horizon.

SETTING

Japan.

POPULATION

A hypothetical cohort of 50-year-old diabetic patients with MASLD risk-stratified according to degree of obesity and progression to cirrhosis. Metabolic dysfunction-associated steatotic liver (MASL), metabolic dysfunction-associated steatohepatitis (MASH) and MASH cirrhosis are progressive manifestations of this specific type of liver disease.

INTERVENTION

Abdominal ultrasound (US), US with alpha-fetoprotein (AFP), US with AFP and lectin-reactive alpha-fetoprotein (AFP-L3), CT, extracellular contrast-media-enhanced MRI (ECCM-MRI), gadoxetic acid-enhanced MRI (EOB-MRI) and no screening.

MAIN OUTCOME MEASURE

Costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), early-stage HCC cases, advanced-stage HCC cases and HCC-related deaths.

RESULTS

EOB-MRI is the most cost-effective screening method for non-obese diabetic patients with MASH cirrhosis and for obese diabetic patients with MASH and MASH cirrhosis. Cost-effectiveness was sensitive to HCC incidence in non-obese diabetic patients with MASH cirrhosis and obese diabetic patients with MASH, and the adherence rate of HCC screening in obese diabetic patients with MASH. When the semiannual HCC incidence was between 0.008 and 0.0138 in non-obese diabetic patients with MASH cirrhosis, US with AFP was more cost-effective than EOB-MRI. Cost-effectiveness acceptability curves showed that EOB-MRI was 50.7%, 96.0% and 99.9% cost-effective in obese diabetic patients with MASH and non-obese diabetic patients with MASH cirrhosis, and obese diabetic patients with MASH cirrhosis at a willingness-to-pay level of $50 000 per QALY gained. Compared with no screening in 100 000 non-obese diabetic patients with MASH cirrhosis and obese diabetic patients with MASH cirrhosis, EOB-MRI reduced total costs by US$69 million and by US$142 million, increased lifetime effectiveness by 12 546 QALYs and by 15 815 QALYs, detected 17 873 and 21 014 early-stage HCC cases, and averted 2068 and 2471 HCC-related deaths, respectively.

CONCLUSIONS

Of all HCC screening methods for diabetic patients with MASH cirrhosis, EOB-MRI yields the greatest cost-saving with the highest QALYs, detects the greatest number of early-stage HCC cases and averts the greatest number of advanced-stage HCC cases and HCC-related deaths. The findings provide important insights for the precise implementation of risk-stratified HCC surveillance to reduce morbidity and mortality and improve the quality of life in diabetic patients with MASLD.

Non-contrast abbreviated MRI for the detection of hepatocellular carcinoma in patients with Liver Imaging Reporting and Data System LR-3 and LR-4 observations in MRI

BACKGROUND AND AIMS

With ultrasound sensitivity limited in hepatocellular carcinoma (HCC) surveillance and few prospective studies on non-contrast abbreviated MRI (NC-AMRI), this study aimed to assess its diagnostic performance in detecting HCC.

METHODS

This prospective study involved cirrhotic patients with contrast-enhanced MRI (CE-MRI) Liver Imaging Reporting and Data System (LI-RADS) LR-3 and LR-4 observations detected during HCC surveillance. Patients underwent average 3 complete CE-MRI rounds at 3-6 months interval, with approximately 12-month follow-up. NC-AMRI included diffusion-weighted (DWI), T2-weighted imaging (T2WI), and T1-weighted imaging (T1WI). NC-AMRI protocol images were analysed for diagnostic performance, with subgroup analyses. CE-MRI and NC-AMRI images were independently reviewed by 2 experienced radiologists, with inter-reader agreement assessed with Kappa coefficient. The reference standard was the American Association for the Study of Liver Diseases-defined presence of arterial hypervascularity and washout during the portal-venous or delayed phases on CE-MRI.

RESULTS

In 166 CE-MRI follow-ups of 63 patients (median age: 63 years; 60.3% male, 39.7% female), 12 patients developed HCC, with average size of 19.6 mm. The NC-AMRI (DWI + T2WI + T1WI) showed 91.7% sensitivity (95%CI, 61.5-99.8) and 91.6% specificity (95%CI, 86.0-95.4), area under receiver operating characteristic 0.92 (95%CI, 0.83-1.00). Across different Body Mass Index categories, lesion size, Child-Turcotte-Pugh classes, Albumin-Bilirubin (ALBI) grades, and Model for End-Stage Liver Disease classes, sensitivity remained consistent. However, specificity differed significantly between ALBI grade 1 and 2 (86.7% vs. 98.4%, P = .010), and between viral and non-viral cirrhosis (93.8% vs. 80.8%, P = .010).

CONCLUSIONS

NC-AMRI proved clinically feasible, and exhibits high diagnostic performance in HCC detection.

ADVANCES IN KNOWLEDGE

This study highlights efficacy of NC-AMRI in detecting HCC among cirrhotic patients with LR-3 and LR-4 observations, representing significant progress in HCC surveillance.

Impact of COVID-19 pandemic on hepatocellular carcinoma surveillance in British Columbia, Canada: An interrupted time series study

We assessed the impact of the COVID-19 pandemic on hepatocellular carcinoma (HCC) surveillance among individuals with HCV diagnosed with cirrhosis in British Columbia (BC), Canada. We used data from the British Columbia Hepatitis Testers Cohort (BC-HTC), including all individuals in the province tested for or diagnosed with HCV from 1 January 1990 to 31 December 2015, to assess HCC surveillance. To analyse the impact of the pandemic on HCC surveillance, we used pre-policy (January 2018 to February 2020) and post-policy (March to December 2020) periods. We conducted interrupted time series (ITS) analysis using a segmented linear regression model and included first-order autocorrelation terms. From January 2018 to December 2020, 6546 HCC screenings were performed among 3429 individuals with HCV and cirrhosis. The ITS model showed an immediate decrease in HCC screenings in March and April 2020, with an overall level change of -71 screenings [95% confidence interval (CI): -105.9, -18.9]. We observed a significant decrease in HCC surveillance among study participants, regardless of HCV treatment status and age group, with the sharpest decrease among untreated HCV patients. A recovery of HCC surveillance followed this decline, reflected in an increasing trend of 7.8 screenings (95% CI: 0.6, 13.5) per month during the post-policy period. There was no level or trend change in the number of individuals diagnosed with HCC. We observed a sharp decline in HCC surveillance among people living with HCV and cirrhosis in BC following the COVID-19 pandemic control measures. HCC screening returned to pre-pandemic levels by mid-2020.

Performance and effectiveness of hepatocellular carcinoma screening in individuals with HBsAg seropositivity in China: a multicenter prospective study

Current guidelines recommend hepatocellular carcinoma (HCC) surveillance for at-risk individuals, including individuals with hepatitis B virus infection. However, the performance and survival benefits of annual screening have not been evaluated through multicenter prospective studies in a Chinese population. Between 2017 and 2021, we included 14,426 participants with hepatitis B surface antigen seropositivity in an annual HCC screening study in China using a multicenter prospective design with ultrasonography and serum alpha-fetoprotein. After four rounds of screening and follow-up, the adjusted hazard ratios of death after correction for lead-time and length-time biases for screen-detected cancers at the prevalent and incident rounds were 0.74 (95% confidence interval = 0.60-0.91) and 0.52 (95% confidence interval = 0.40-0.68), respectively. A meta-analysis demonstrated that HCC screening was associated with improved survival after adjusting for lead-time bias. Our findings highlight the 'real-world' feasibility and effectiveness of annual HCC screening in community settings for the early detection of HCC and to improve survival.

Utilization of Hepatocellular Carcinoma Surveillance Programs in Patients With Cirrhosis: A Systematic Review and Meta-Analysis

Patients with cirrhosis are advised to undergo hepatocellular carcinoma (HCC) surveillance every 6 months. Routine surveillance is associated with early tumor detection and improved survival. However, surveillance is underutilized. We aimed to characterize the uptake of HCC surveillance in cirrhotic patients following the implementation of interventional programs. We performed a comprehensive literature search of major databases (from inception to October 2020). Surveillance was defined as having an abdominal sonogram every 6 months. Nine studies were included for meta-analysis which involved 4550 patients. The etiology of liver cirrhosis was largely due to hepatitis C or B (n=2023), followed by alcohol (n=857), and nonalcoholic steatohepatitis (n=432). Patients enrolled in surveillance programs were 6 times more likely to undergo abdominal sonography when compared with standard of care (odds ratio=6.00; 95% confidence interval: 3.35-10.77). On subgroup analysis, clinical reminders were associated with a 4 times higher rate of HCC surveillance compared with standard of care (odds ratio=3.80; 95% confidence interval: 2.25-6.39). Interventional programs significantly improve the rate of HCC surveillance. This is clinically impactful and should be considered as a means for improving surveillance rates.

Application of ultrasound combined with enhanced MRI by Gd-BOPTA in diagnosing hepatocellular carcinoma

OBJECTIVE

This study aimed to probe into the diagnostic level and clinical value of ultrasound combined with enhanced MRI by Gd-BOPTA in hepatocellular carcinoma (HCC).

METHODS

A total of 58 suspected HCC patients in our hospital from January 2016 to November 2020 were collected as the research subjects, including 37 HCC and 21 non-HCC patients. The diagnostic results of ultrasound and enhanced MRI by Gd-BOPTA were compared, and the microvascular invasion in patients was assessed. The independent risk factors of microvascular invasion were analyzed by logistics regression, and the diagnostic value of these factors was tested by ROC.

RESULTS

The specificity, sensitivity and accuracy of enhanced MRI by Gd-BOPTA were 89.19%, 90.48% and 94.59%, respectively. The specificity, sensitivity and accuracy of ultrasound were 85.71%, 72.97% and 91.89%, and those of combined diagnosis were 76.19%, 97.30%, and 89.66%, respectively. The confirmation rate of microvascular invasion of enhanced MRI by Gd-BOPTA was dramatically higher than with ultrasound. Tumor diameter, comorbid cirrhosis and differentiation degree were independent risk factors of microvascular invasion, and ROC curve revealed that the area under the curve (AUC) of these risk factors was > 0.6.

CONCLUSION

Enhanced MRI by Gd-BOPTA combined with ultrasound has good diagnostic value in HCC patients, and it can be widely used in early HCC diagnosis and clinical examination.

Alternative approach of hepatocellular carcinoma surveillance: abbreviated MRI

This review focuses on emerging abbreviated magnetic resonance imaging (AMRI) surveillance of patients with chronic liver disease for hepatocellular carcinoma (HCC). This surveillance strategy has been proposed as a high-sensitivity alternative to ultrasound for identification of patients with early-stage HCC, particularly in patients with cirrhosis or obesity, in whom sonographic visualization of small tumors may be compromised. Three general AMRI approaches have been developed and studied in the literature - non-contrast AMRI, dynamic contrast-enhanced AMRI, and hepatobiliary phase contrast-enhanced AMRI - each comprising a small number of selected sequences specifically tailored for HCC detection. The rationale, general technique, advantages and disadvantages, and diagnostic performance of each AMRI approach is explained. Additionally, current gaps in knowledge and future directions are discussed. Based on emerging evidence, we cautiously recommend the use of AMRI for HCC surveillance in situations where ultrasound is compromised.

Hepatocellular carcinoma in Ghana: a retrospective analysis of a tertiary hospital data

INTRODUCTION

Hepatocellular carcinoma (HCC) is a cancer of global public health concern because of its high incidence and mortality. The impact is greatest in areas with high prevalence of its major risk factors including chronic hepatitis B virus (HBV). HBV is endemic in Ghana but a comprehensive data on HCC is lacking. The aim of this study was to describe the clinical, laboratory and radiological features of HCC at the Korle Bu Teaching Hospital in Ghana.

METHODS

The medical records of 194 HCC cases attended to at the Gastrointestinal Clinic of the Korle Bu Teaching Hospital between January 2015 and December 2018 were retrospectively analyzed for demographic, clinical, laboratory and radiological data.

RESULTS

The male: female ratio was 2:1 and mean age was 45.2 years. Weight loss and abdominal pain were the major presenting symptoms. No patients were identified through surveillance. HBsAg was positive in 109/145 (75.2%) of cases tested. Sixty-five (59.6%) of 109 HBsAg positives were aware of their HBsAg status but only 3 were receiving medical follow ups prior to the diagnosis of HCC. Raised alpha-fetoprotein level >165.2 IU/ML was found in 53.9%. One hundred and forty-four patients were eligible for only analgesia.

CONCLUSION

HBV infection is the leading aetiologial risk factor associated with HCC. Majority of HBV carriers are aware of their status but do not receive care prior to HCC diagnosis. Majority present late and are eligible for only palliative treatment. Improvement in the health seeking behavior of HBV carriers can aid early detection of HCC.

A critical appraisal of the use of ultrasound in hepatic steatosis

Introduction: Nonalcoholic fatty liver disease (NAFLD) spans steatosis through nonalcoholic steatohepatitis (NASH), fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). NAFLD carries an increased risk of cardio-metabolic and liver-related events accounting for a substantial economic burden. Given that the natural history of NAFLD is critically dependent on the stage of fibrosis, non-invasively identifying the subgroup of patients at a higher risk of progressive disease is key. Areas covered: This review highlights the recent developments in the use of ultrasound-based techniques in NAFLD and their performance in predicting metabolic derangements, cardiovascular risk, and progression of liver disease, notably including diagnosis of fibrosing NASH, identification, and treatment of HCC. Expert opinion: Our ability to identify NAFLD patients and to estimate steatofibrosis with various ultrasound-based techniques has undergone tremendous progress over the last few years. However, it is more difficult to capture the inflammatory component of NASH with such ultrasound-assisted techniques. Moreover, semi-quantitative, quantitative, elastographic, and contrast-enhanced ultrasound techniques are increasingly being appreciated and made available but not all such techniques will gain success in the clinical and research area. Therefore, further research will precisely define the role of the most innovative ultrasonographic techniques, while reducing costs and increasing feasibility.