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Screening for hepatocellular carcinoma in chronic liver disease: a systematic review
Background:
Guidelines recommend routine screening for hepatocellular carcinoma (HCC) in high-risk patients, but the strength of evidence supporting these recommendations is unclear.
Purpose:
To review the benefits and harms of HCC screening in patients with chronic liver disease.
Data Sources:
MEDLINE, PsycINFO, and ClinicalTrials.gov from inception to April 2014; Cochrane databases to June 2013; reference lists; and technical advisors.
Study Selection:
English-language trials and observational studies comparing screening versus no screening, studies of harms, and trials comparing different screening intervals.
Data Extraction:
Mortality and adverse events were the outcomes of interest. Individual-study quality and the overall strength of evidence were dual-reviewed using published criteria.
Data Synthesis:
Of 13,801 citations, 22 studies met inclusion criteria. The overall strength of evidence on the effects of screening was very low. One large trial of patients with hepatitis B found decreased HCC mortality with periodic ultrasonographic screening (rate ratio, 0.63 [95% CI, 0.41 to 0.98]), but the study was limited by methodological flaws. Another trial in patients with hepatitis B found no survival benefit with periodic α-fetoprotein screening. In 18 observational studies, screened patients had earlier-stage HCC than clinically diagnosed patients, but lead- and length-time biases confounded the effects on mortality. Two trials found no survival differences between shorter (3- to 4-month) and longer (6- to 12-month) screening intervals. Harms of screening were not well-studied.
Limitations:
Only English-language studies were included. The evidence base is limited by methodological issues and a paucity of trials.
Conclusion:
There is very-low-strength evidence about the effects of HCC screening on mortality in patients with chronic liver disease. Screening tests can identify early-stage HCC, but whether systematic screening leads to a survival advantage over clinical diagnosis is uncertain.
Primary Funding Source:
U.S. Department of Veterans Affairs Quality Enhancement Research Initiative.
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