Partial cure of chronic hepatitis B: potential implications for HCC surveillance?

Abstract

Surveillance of hepatocellular carcinoma (HCC), via 6-monthly ultrasonography with alpha-fetoprotein testing, is currently recommended for patients with chronic liver disease at risk of HCC. Unlike other liver diseases where HCC occurs almost exclusively in patients with cirrhosis, up to 30% of hepatitis B virus (HBV)-associated HCC occurs in patients without cirrhosis.1 Thus, HCC surveillance is additionally recommended for individuals with non-cirrhotic chronic HBV on reaching a certain age, men >40 years and women >50 years in endemic countries, and as early as the third decade of life for individuals from Africa.2 This recommendation is based on a perceived 0.2% per year HCC incidence which was considered cost-effective for HCC surveillance.3 However, a more recent study found an HCC incidence of 0.4% per year to be cost-effective for surveillance at a higher willingness-to-pay level, with a major influence of surveillance adherence.4 HCC surveillance is underused in clinical practice. A meta-analysis found the rate of HCC surveillance among patients with chronic HBV and no cirrhosis to be 32%.1 Low adherence to HCC surveillance has been attributed to multiple patient-related, provider-related and health system-related barriers, including logistical and budgetary difficulties in administering a surveillance programme that can support large numbers of at-risk patients. Since patient adherence is crucial for the success of any surveillance strategy,4 improvement in risk stratification would allow optimisation of surveillance resources. This may be especially true for patients with inactive chronic HBV without cirrhosis, which comprises up to 70% of patients with chronic HBV5 and …