This document was first published in October 2020, and reviewed in January 2021
The incidence of HCC in patients with compensated cirrhosis is 1-2% per year. NICE recommends offering HCC surveillance to patients with cirrhosis and to selected patients with chronic hepatitis B infection.* EASL recommends HCC surveillance for patients with chronic hepatitis C infection and advanced fibrosis. **
For HCC surveillance to be effective, curative treatment options of liver resection, tumour ablation or liver transplantation must be available to patients in whom HCC is detected. Whilst surveillance increases detection of HCC before it becomes symptomatic, systematic reviews provide conflicting evidence for improved survival.
Provision of HCC surveillance during the pandemic
Cirrhosis management and therefore HCC surveillance was deferred at most sites during the first wave of COVID-19. However, the ongoing impact of the pandemic is affecting services in a non-uniform way and at different times across the UK so whilst some hospitals are under critical pressure others are able function more normally. In the event that hospitals are under critical pressure then HCC surveillance may need to be deferred but it is important to recognise this will result in morbidity and mortality as well. Therefore, service recovery should be planned to resume standard of care as soon as local circumstances allow.
When planning recovery of services take the following into account:
- Ensure there is a robust mechanism in place for timely review of results to avoid delays in recall for follow-up imaging and diagnosis
- Coincide surveillance with cirrhosis monitoring blood tests and clinical reviews to minimise visits to hospital or other healthcare settings. Cirrhosis clinical reviews are possible by telephone or video platforms for most patients who are suitable for HCC surveillance if normal outpatient services are being adapted to new ways of working.
Patient selection for surveillance
Patients enrolled into a surveillance programme should have a good understanding of the purpose of surveillance, its aims and its limitations. Patients with compensated cirrhosis and good performance status should be prioritised for surveillance.
- Those patients with Child-Pugh score >B7 and / or ascites that is not controlled with diuretics will not tolerate anticancer treatment for HCC and surveillance is not recommended for these individuals. (The opportunity could be taken however to consider candidacy for liver transplant assessment referral).
- Frailty and advanced comorbidities also impact on patients’ suitability for surveillance when these comorbidities have a major impact on life expectancy.
- Curative treatments require general anaesthesia and this provides a measure of the performance status required.
A Child-Pugh and performance status calculator for patients at risk of HCC is available to download at: https://www.basl.org.uk/index.cfm/content/page/cid/34
* Hepatitis B recommendations
- with significant fibrosis or cirrhosis (F2-4).
- without significant fibrosis or cirrhosis if > 40 years and has a family history of HCC and HBV DNA ≥ 20,000 IU/ml.
** Hepatitis C recommendation
- advanced fibrosis defined as ≥F3
RL Jones, IA Rowe & the BSG Liver Section
Leeds Liver Unit, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, UK
NICE CG 50 https://www.nice.org.uk/guidance/ng50 (accessed 25/06/20)
NICE CG 165 https://www.nice.org.uk/guidance/cg165 (accessed 25/06/20)
Taylor EJ et al. odelling the benefits and harms of surveillance for hepatocellular carcinoma: Information to support informed choices. Hepatology 2017;66:1546-1555
Roskilly A, Rowe IA. Surveillance for hepatocellular carcinoma. Clinical Medicine 2018;18:66-69
Kanwal F, Singal AG. Surveillance for hepatocellular carcinoma: Current best practice and future direction. Gastroenterology 2019;157:54-64