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Pragmatic Approach to Hepatocellular Carcinoma Diagnosis in High-Incidence, Resource-Limited Settings in Africa
Gregory D Kirk1,2, Sara Nsibirwa3, Jim K Aizire1
1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Insights
A new integrated diagnostic strategy for hepatocellular carcinoma (HCC) in sub-Saharan Africa combines clinical data with one confirmatory test. This pragmatic approach improves diagnostic yield in resource-limited settings.
Area of Science:
- Hepatology
- Oncology
- Global Health
Background:
- Hepatocellular carcinoma (HCC) presents a significant mortality challenge in sub-Saharan Africa.
- Limited availability of advanced imaging (CT, MRI) hinders effective HCC diagnosis in the region.
Purpose of the Study:
- To develop and evaluate a pragmatic, resource-adaptable diagnostic strategy for HCC in sub-Saharan Africa.
- To optimize HCC case definition for improved diagnostic yield in resource-constrained environments.
Main Methods:
- A multisite study in Uganda involving 649 suspected HCC cases.
- Data collection included clinical, ultrasonographic, biochemical (alpha-fetoprotein), and pathological criteria.
- Concordance analysis and percentage-confirmed yield were assessed using various HCC case definitions.
Main Results:
- An integrated HCC case definition combining clinical criteria with one confirmatory test significantly increased diagnostic yield.
- Ultrasonography, alpha-fetoprotein (AFP), and pathology confirmed 91%, 57%, and 17% of clinically defined HCC cases, respectively.
- The integrated definition maximized yield while maintaining diagnostic rigor, with minimal additional yield from AFP or pathology beyond ultrasound.
Conclusions:
- An integrated HCC case definition is proposed as a pragmatic and adaptable approach for clinical diagnosis and research in sub-Saharan Africa.
- This strategy can support regional efforts to develop novel diagnostics and treatments for HCC.
- The proposed definition is readily implementable to address the substantial HCC burden in the region.
Purpose:
Hepatocellular carcinoma (HCC) is common and deadly in sub-Saharan Africa, where advanced imaging techniques, such as computerized tomography and magnetic resonance imaging, are scarce. The purpose of this study was to develop a pragmatic HCC diagnostic strategy for such settings.
Methods:
We evaluated standardized protocol-collected data on clinical, ultrasonographic, biochemical, and pathological criteria in a multisite study of 649 suspected HCC cases in Uganda. Participants underwent standardized interviews, clinical assessments, and ultrasound examinations by trained staff with alpha-fetoprotein (AFP) testing at a central laboratory, and pathology was obtained for selected participants. Concordance analysis and percentage-confirmed yield using different HCC case definitions were performed, with survival follow-up as a validation measure.
Results:
The median age was 45 years, 68% were male, and 45% had chronic hepatitis B infection. Ultrasonographic, biochemical (AFP), and pathological definitions confirmed 91%, 57%, and 17% of clinically defined HCC cases, respectively. The median survival after diagnosis was 46 days. An integrated HCC case definition that combined clinical criteria with one confirmatory test increased the percentage-confirmed yield by 3.7% (ultrasonographic), 37.7% (biochemical), and 77.7% (pathologic) over the clinical definition alone. Yield from AFP or pathology beyond ultrasound was minimal. Survival did not differ appreciably by HCC case definition. This integrated HCC case definition maintained diagnostic rigor while maximizing yield.
Conclusion:
We propose an integrated HCC case definition as a pragmatic, resource-adaptable approach for clinical diagnosis and research in sub-Saharan Africa. This definition can be readily implemented and can support regional collaborative efforts to develop novel diagnostics and improved treatments to ameliorate the heavy HCC burden.
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