Alpha-fetoprotein and/or liver ultrasonography for liver cancer screening in patients with chronic hepatitis B

Evidence Summaries

Level of Evidence = C
Screening of hepatocellular cancer by AFP plus ultrasonography may result in more cancers found, but there is insufficient evidence on the effect of screening on prognosis.

A Cochrane review 1 included 3 studies with a total of 20,629 subjects. One trial (n = 18,816) compared bi-annual AFP plus US screening with no screening for five years. Participants were diagnosed either with HBsAg positive (91.6%) or HBsAg negative (8.4%) chronic hepatitis. No data on all-cause mortality were available. The two groups did not differ significantly regarding hepatocellular carcinoma (HCC) mortality (OR 0.81; 95% CI 0.54 to 1.22). Number of patients with HCC was significantly increased in the screeened group (OR 1.37; 95% CI 1.00 to 1.88). Most HCCs in the screened group, but none in the control group, were at an early stage. The survival rate of patients with resected HCC in the screened group reached 52.7% after three and five years, but was 0% for those in the control group. The authors' estimated lead-time for HCC was 5.4 months, suggesting that screening prolonged the survival of HCC. Another trial (n = 1069, all HBsAg positive) compared AFP plus US versus AFP screening, but could not decide which approach was superior due to the small sample size (number of detected HCC: OR 0.74; 95% CI 0.26 to 2.12). In a third trial, participants were randomly allocated to a four-month screening group (n = 387) or an annual screening group (n = 357). The cumulative four-year survival was reported as insignificantly different between the groups: 45.3% in the four-monthly group and 42.7% in the annual group.

Comment: The quality of evidence is downgraded by imprecise results (few outcome events) and by limitations in study quality (e.g. inadequate or unclear allocation concealment and lack of blinding).

References

1. Wun YT, Dickinson JA. Alpha-fetoprotein and/or liver ultrasonography for liver cancer screening in patients with chronic hepatitis B. Cochrane Database Syst Rev 2012;(2):CD002799.  [PMID:12804438]


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