Hepatocellular carcinoma screening in a tertiary hospital. What are we missing?

Screening for hepatocellular carcinoma (HCC) aims to detect early tumors, with a positive impact on survival. In clinical practice there are several challenges on the application of HCC screening: patients with unknown liver disease, poor patient adherence or problems in the health care system, leading to an underperformance. We aim to evaluate the performance of the HCC screening, the reasons of missed or delayed diagnosis, and prognostic implications in patients with HCC in a tertiary center.

Retrospective study including patients with an HCC diagnosis, that have been discussed by a liver tumors board from 2020 to 2023 in a tertiary hospital. HCC screening was defined according to the EASL recommendations. Considering the target population for screening, subgroups were considered and compared: (a) diagnosed through screening; (b) missed screening due to suboptimal patient adherence and/or systemic healthcare inefficiencies; (c) undiagnosed advanced chronic liver disease (uACLD), that would have indication for surveillance if already diagnosed. For patients diagnosed through screening, we considered a margin of 2 months (8 months) as "complete surveillance" and between 8 to 12 months as "incomplete surveillance". To access the survival benefit, we compared the overall survival of the screened population and those do not diagnose through screening.

We included 174 patients, 136 had advanced chronic liver disease (ACLD): 70% Child-Pugh (CP) A; 20% CP B; 10% CP C. The most common etiologic factor was excessive alcohol consumption (37%). The proportion of patients diagnosed in screening was 26%. Regarding Barcelona Clinic Liver Cancer (BCLC) stage at diagnosis, 4% BCLC-0, 37% BCLC-A, 10% BCLC-B, 33% BCLC-C and 15% BCLC-D. Patients in subgroup (a) had HCC diagnosed at earlier stages (BCLC-0 and BCLC-A). The subgroup (c) had a higher proportion CP B and C (p = 0.008), vascular invasion (p = 0.01), extrahepatic involvement (p = 0.052) and hepatic dysfunction according to ALBI score (p < 0.001) at time of diagnosis. Overall survival was significantly higher for screened group.

In our cohort, only about a quarter of HCC cases were diagnosed through screening, with impact on survival. Among patients with indication for screening, only one third achieved diagnostic yield. Our findings emphasize the need to improve HCC screening strategies and the pivotal role of primary care in the early diagnosis of underlying liver disease.