HES V2.0 validation and performance compared to GALAD and ASAP in the HEDS cohort

Abstract

Background

We previously developed Hepatocellular Carcinoma Early Detection Screening (HES) V2.0, biomarker panel (age, ALT, platelets, etiology, AFP, AFP L3, DCP and their gradient over the past one year) for early detection of HCC among patients with cirrhosis. We externally validated HES V2.0 and compared its performance to HES V1.0, GALAD, and ASAP.

Methods

We conducted a prospective-specimen collection, retrospective-blinded-evaluation (PRoBE) cohort study in the HEDS (Hepatocellular Carcinoma Early Detection Strategy) 1,485 cirrhosis cohort (119 developed HCC). Patient- and test-level true positive rate (TPR) for HCC were calculated at 6, 12, 24 months before HCC diagnosis based on a threshold at a fixed false positive rate (FPR) of 10% and 18.1% - the latter corresponded to GALAD cut-off of -1.36.

Results

HES V2.0 and GALAD had same AUROC (0.79) but different TPR/FPRs. At the FPR of 10%, HES V2.0 had 2.0%, 6.7%, and 6.0% higher TPR (sensitivity) than GALAD within 6, 12, and 24 months before HCC diagnosis (one-sided p-values 0.24, 0.025, 0.078, respectively). At 18.1% FPR, GALAD had 6% and 2% higher sensitivity than HES V2.0 within 6 and 12 months before HCC and similar sensitivity within 24 months before HCC diagnosis (all p-values >0.05).The sensitivity for HES V2.0 was 11.9% higher than HES V1.0 at 12 months (p=0.007). The sensitivity for HES V2.0 was considerably (10.9-16.3%) higher than ASAP. For patients with available labs to calculate gradients over time, the sensitivity of HES V2.0 was 3.5-8.7% higher than GALAD at all time points of testing before HCC (8.7% to 24.0% relative increase) with p<0.05 for several comparisons.

Conclusions

In a phase 3 biomarker validation study, HES V2.0 had higher sensitivity than ASAP for HCC detection, and a similar or higher sensitivity than GALAD only at 12 months before HCC diagnosis at 10% FPR and when over time gradients in AFP, AFP L3, and DCP are available.

Impact and Implications

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality, with early detection being critical for improving survival outcomes. This study provides a rigorous phase 3 validation of the HES V2.0 biomarker panel, demonstrating its superior or comparable sensitivity to established models like GALAD and ASAP in a large, diverse U.S. cirrhosis cohort. The findings are particularly impactful for clinicians and researchers focused on liver cancer surveillance, as HES V2.0 offers enhanced detection performance, especially when longitudinal biomarker data are available. These results support the integration of HES V2.0 into clinical workflows and future trials, potentially improving early HCC detection and enabling timely curative interventions for at-risk patients.