肝硬化患者肝细胞癌筛查与癌症相关死亡率降低之间无关联

StephenW

No Association Between Screening for Hepatocellular Carcinoma and Reduced Cancer-Related Mortality in Patients With Cirrhosis [url=]Andrew M. Moon[/url]
, [url=]Noel S. Weiss[/url]
, [url=]Lauren A. Beste[/url]
, [url=]Feng Su[/url]
, [url=]Samuel B. Ho[/url]
, [url=]Ga-Young Jin[/url]
, [url=]Elliott Lowy[/url]
, [url=]Kristin Berry[/url]
, [url=]George N. Ioannou[/url][url=]Correspondence information about the author George N. Ioannou[/url]Email the author George N. Ioannou

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DOI: https://doi.org/10.1053/j.gastro.2018.06.079 |

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Background & AimsScreening patients with cirrhosis for hepatocellular carcinoma (HCC) has been recommended. We conducted a matched case–control study within the US Veterans Affairs (VA) health care system to determine whether screening by abdominal ultrasonography (USS) and/or by measuring serum level of α-fetoprotein (AFP) was associated with decreased cancer-related mortality in patients with cirrhosis.


MethodsWe defined cases (n = 238) as patients with cirrhosis who died of HCC from January 1, 2013 through August 31, 2015 and had been in VA care with a diagnosis of cirrhosis for at least 4 years before the diagnosis of HCC. We matched each case to 1 control (n = 238), defined as a patient with cirrhosis who did not die of HCC and had been in VA care for at least 4 years before the date of the matched case’s HCC diagnosis. Controls were matched to cases by year of cirrhosis diagnosis, race and ethnicity, age, sex, etiology of cirrhosis, Model for End-Stage Liver Disease score, and VA medical center. We identified all USS and serum AFP tests performed within 4 years before the date of HCC diagnosis in cases or the equivalent index date in controls and determined by chart extraction (blinded to case or control status) whether these tests were performed for screening.


ResultsThere were no significant differences between cases and controls in the proportions of patients who underwent screening USS (52.9% vs 54.2%), screening measurement of serum AFP (74.8% vs 73.5%), screening USS or measurement of serum AFP (81.1% vs 79.4%), or screening USS and measurement of serum AFP (46.6% vs 48.3%) within 4 years before the index date, with or without adjusting for potential confounders. There also was no difference in receipt of these screening tests within 1, 2, or 3 years before the index date.


ConclusionsIn a matched case–control study of the VA health care system, we found that screening patients with cirrhosis for HCC by USS, measurement of serum AFP, either test, or both tests was not associated with decreased HCC-related mortality. We encourage additional case–control studies to evaluate the efficacy of screening for HCC in other health care systems, in which available records are sufficiently detailed to enable identification of the indication for USS and AFP tests.



Keywords:Surveillance, Survival, [url=https://www.gastrojournal.org/action/doSearch?searchType=quick&occurrences=all<rlSrch=true&searchScope=series&searchText=Liver Cancer&seriesISSN=0016-5085]Liver Cancer[/url], [url=https://www.gastrojournal.org/action/doSearch?searchType=quick&occurrences=all<rlSrch=true&searchScope=series&searchText=Liver Transplantation&seriesISSN=0016-5085]Liver Transplantation[/url]

StephenW

肝硬化患者肝细胞癌筛查与癌症相关死亡率降低之间无关联
Andrew M. Moon
，Noel S. Weiss
，Lauren A. Beste
，冯苏
，Samuel B. Ho
，Ga-Young Jin
，Elliott Lowy
，克里斯汀贝瑞
，George N. Ioannou'关于作者的相关信息George N. Ioannou给作者George N. Ioannou发邮件
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DOI：https：//doi.org/10.1053/j.gastro.2018.06.079 |
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背景与目的

已经推荐筛查肝硬化患者的肝细胞癌（HCC）。我们在美国退伍军人事务部（VA）医疗保健系统内进行了一项匹配的病例对照研究，以确定腹部超声检查（USS）筛查和/或通过测量血清甲胎蛋白（AFP）水平与癌症相关性降低相关肝硬化患者的死亡率。
方法

我们将病例（n = 238）定义为2013年1月1日至2015年8月31日死于HCC的肝硬化患者，并且在诊断为HCC之前已经在VA治疗中诊断为肝硬化至少4年。我们将每个病例与1个对照组（n = 238）相匹配，定义为肝硬化患者，他们没有死于HCC并且在匹配病例的HCC诊断日期之前已经在VA护理中至少4年。对照组与肝硬化诊断年龄，种族和种族，年龄，性别，肝硬化病因，终末期肝病模型评分和VA医疗中心相匹配。我们确定了在HCC诊断之前4年内进行的所有USS和血清AFP测试或对照中的等效指数日期，并通过图表提取（不知情或控制状态）确定这些测试是否进行筛选。
结果

病例组和对照组之间在接受筛查USS的患者比例（52.9％vs 54.2％），血清AFP筛查测量值（74.8％vs 73.5％），筛查USS或血清AFP测量值（81.1％vs 79.4％），或在指数日期前4年内筛查USS和血清AFP测量值（46.6％对48.3％），无论是否调整潜在的混杂因素。在索引日期之前的1年，2年或3年内，收到这些筛选测试也没有差异。
结论

在VA医疗保健系统的匹配病例对照研究中，我们发现通过USS筛查肝硬化HCC患者，测量血清AFP，测试或两种测试均与HCC相关死亡率降低无关。我们鼓励进行额外的病例对照研究，以评估在其他医疗保健系统中筛查HCC的效果，其中可用记录足够详细，以便能够识别USS和AFP检测的适应症。
关键词：
监测，生存，肝癌，肝移植

StephenW

Should We Abandon Current Hepatocellular Carcinoma Screening Practices?
Gregory S. Cooper'Correspondence information about the author Gregory S. CooperEmail the author Gregory S. Cooper
Division of Gastroenterology, University Hospitals Cleveland Medical Center and Case Western Reserve University and Case Comprehensive Cancer Center, Cleveland, Ohio
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DOI: https://doi.org/10.1053/j.gastro.2018.09.001 |

See “No association between screening for hepatocellular carcinoma and reduced cancer-related mortality in patients with cirrhosis,” by Moon AM, Weiss NS, Beste LA, et al, on page 1128.

Hepatocellular carcinoma (HCC) is currently the third leading cause of cancer death worldwide1 and is the third most common and fatal gastrointestinal cancer in the United States.2 Although the estimated annual incidence of 42,000 cases in the United States is lower than several other common cancers, it is one of the few malignancies that is increasing in incidence and mortality in both men and women.2 The incidence is expected to continue to remain high owing to increases in the prevalence of certain chronic liver diseases, notably nonalcoholic fatty liver disease.3 Because survival is strongly associated with stage at diagnosis, routine surveillance with ultrasound examination with or without alpha-fetoprotein (AFP) in at-risk patients is generally recommended by all professional societies worldwide (Table 1). However, the data supporting surveillance are largely limited to observational studies, which are subject to multiple biases. A frequently cited randomized trial from China showed a 37% decrease in HCC mortality with semiannual ultrasound examinations and AFP,4 but had several methodologic concerns about randomization and follow-up, and was limited to patients with hepatitis B.5 Nonetheless, in the absence of alternative strategies, ultrasound-based surveillance is the current standard of care.
我们应该放弃目前的肝细胞癌筛查实践吗？
Gregory S. Cooper'关于作者的相关信息Gregory S. CooperEmail作者Gregory S. Cooper
美国俄亥俄州克里夫兰市大学医院克利夫兰医疗中心和凯斯西储大学消化科和病例综合癌症中心
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DOI：https：//doi.org/10.1053/j.gastro.2018.09.001 |

参见Moon AM，Weiss NS，Beste LA等人，第1128页，“肝细胞癌筛查与肝硬化患者癌症相关死亡率之间没有关联”。

肝细胞癌（HCC）目前是全球癌症死亡的第三大原因1，并且是美国第三大常见和致命的胃肠癌.2虽然美国估计每年发病42,000例的病例数低于其他几种常见癌症它是少数几个在男性和女性中发病率和死亡率都在增加的恶性肿瘤之一.2由于某些慢性肝病，特别是非酒精性脂肪性肝病的患病率增加，预计发病率仍将继续保持高水平.3由于存活率与诊断阶段密切相关，因此全球所有专业学会通常都会建议对有风险的患者进行常规的超声检查监测（有或没有甲胎蛋白（AFP））（表1）。然而，支持监测的数据主要局限于观察性研究，这些研究受到多种偏见的影响。一项经常被引用的中国随机试验显示，半月超声检查和AFP检查发现HCC死亡率降低37％，但随机化和随访有一些方法学问题，仅限于乙型肝炎患者.5尽管如此，在替代策略中，基于超声的监测是目前的护理标准。

https://www.gastrojournal.org/ar ... 18)34934-5/fulltext