Hepatocellular carcinoma (HCC) is a well known complication of chronic hepatitis B (HBV) infection. The risk appears to be related to the duration of infection. Thus Asian patients who acquire the disease in childhood, by virtue of the long duration of the disease, are at a significantly higher risk of developing HCC than, Alaskan natives or Caucasians (20,105-107). The cumulative probability of developing HCC in patients who are HBsAg-positive has been estimated to be 6% at 5 years and 15% at 10 years. Once HCC develops, the prognosis is very poor. Survival of patients with symptomatic untreated tumours beyond 3 years is rare (108).

The enthusiasm to screen patients with HBV for HCC is based on the premise that earlier detection can offer these patients a chance for potential cure. There are 2 large North American studies of screening in hepatitis B carriers (107,109). One suggests that screening is very effective at finding curable tumours, whereas the other suggests otherwise.

The risk of developing HCC in a non-cirrhotic patient with hepatitis C (HCV) is trivial. Once cirrhosis is present, the cumulative probability of developing HCC is estimated to be 1.4 to 3.3% per year (50,62). Apart from cirrhosis, other factors that increase the patient’s risk for developing HCC include long duration of infection, male gender, greater than 55 years, continued alcohol consumption and co-infection with HBV. Response to interferon treatment appears to confer a protective effect against the development of HCC.

Although routine screening for HCC in patients with HCV is not as widespread as for patients with HBV, this is still practiced in certain community groups. Much of what is known about screening for HCC in patients with HBV also applies to patients with HCV.

There have been no studies to determine whether screening for HCC decreases the disease-specific mortality. Thus the most important piece of information about whether the potential effectiveness of screening is missing. The decision to screen or not screen therefore must rest on other factors.

One of the reasons why screening may not be effective is the poor sensitivity of our screening tests. The currently employed screening tests, which include alpha-fetoprotein and ultrasound, have sensitivities of 50% and 70% respectively (107). Furthermore, HCC tends to occur in patients with cirrhosis, many of whom cannot tolerate a curative surgical resection. Thus the other treatment options left are liver transplantation or alcohol injection of the lesions. The former is only limited to patients who are HBV DNA negative either spontaneously or induced by therapy. The lack of suitable organ donors makes this option available to a limited few. Alcohol injection can be an effective treatment for HCC, but its efficacy is markedly reduced in patients with large tumours (> 5 cm). It is technically difficult to perform in patients with ascites and coagulopathy.

Screening should only be performed when effective curative therapy is possible, and in patient groups where the relative risk of HCC development is high. Screening is also appropriate in patients who have undergone a curative resection for HCC.

In the absence of documented benefit of mass screening, the committee makes no recommendations for or against screening for HCC in HBsAg-positive patients, nor for patients with chronic hepatitis C. Screening may be justified in high risk cases (presence of cirrhosis, long duration of infection, HBV/HCV co-infection, past curative resection for HCC, family history of HCC [HBV only]).

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