Modelling the benefits and harms of surveillance for hepatocellular carcinoma: information to support informed choices

Abstract

Surveillance by ultrasonography for hepatocellular carcinoma (HCC) for individuals with cirrhosis is recommended. There is debate regarding the effectiveness of surveillance in reducing mortality and there is little information on the harms available to patients considering surveillance. The aim of this study was to provide estimates of both the benefit and harms of surveillance. A Markov model was built to simulate outcomes of individuals entering surveillance. Following identification of a focal lesion by ultrasound surveillance further investigations were defined by the EASL-EORTC recall policy. Benefit and harm outcomes are expressed per 1000 patients over 5 years. For every 1000 patients in surveillance over 5 years there are 13 fewer deaths (95% confidence interval 12-14) compared with no surveillance, equating to a number needed to screen to prevent one death from HCC of 77. In comparison, many more individuals experienced harm through surveillance. For every 1000 patients, 150 (95% confidence interval 146-154) had one or more false positive tests equating to a number needed to harm from surveillance of 7. As a consequence of a false positive test, 65 individuals required at least one additional unnecessary CT scan or MRI and 39 required an unnecessary liver biopsy according to the recall policy. Surveillance benefits were sensitive to the incidence of HCC and the mortality benefit achieved by treatment. Harms were sensitive to the rates of false positive testing and the frequency of liver biopsy. Conclusion. There is a balance between the small absolute mortality benefit to surveillance for HCC and the numerically more frequent harms resulting from false positive testing. Implementation of the recently revised AASLD recommendations is predicted to reduce harms from unnecessary liver biopsy. This article is protected by copyright. All rights reserved.

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