Reply
Authors: Ju Dong Yang, William S. Harmsen, Seth W. Slettedahl, Felicity T. Enders, Terry M. Therneau, Lucinda Orsini, W. Ray Kim, Lewis R. Roberts
Journal: Clinical Gastroenterology and Hepatology (2011)

We thank Dr Braillon for his important comments on smoking as an etiology of hepatocellular carcinoma (HCC) and surveillance.1Braillon A. Hepatocellular carcinoma: still in search for evidence-based care.Clin Gastroenterol Hepatololgy. 2011; (in press)PubMed Google Scholar We agree that most studies identify smoking as an independent risk factor for HCC. However, because the magnitude of the association between smoking and HCC is smaller than it is with viral hepatitis, alcohol, or nonalcoholic steatohepatitis (NASH), we did not report smoking as a separate risk factor for HCC. Nevertheless, we strongly agree with Dr Braillon on the importance of efforts to reduce smoking for prevention of HCC. We defined HCC surveillance in the “Clinical Information” subsection of the Methods section.2Yang J.D. Harmsen W.S. Slettedahl S.W. et al.Factors that affect risk for hepatocellular carcinoma and effects of surveillance.Clin Gastroenterol Hepatol. 2011; 9: 617-623Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar Thirty-one percent of patients in our study (136 of 443; the surveillance status in 17 patients was unknown) were under surveillance at the time of HCC diagnosis (see Table 1 in the article). This is higher than the available national statistics noted by Dr Braillon. This may be partly due to selection bias, as our patients were seen at a tertiary medical center and, therefore, might represent a selected group of patients who are different from the general population in terms of access to medical care, socioeconomic status, etc. The patients may also have been selected by their physicians for referral to our center because they were diagnosed at an earlier stage more amenable to treatment. The higher reported rate of surveillance in our study may also have been related to the definition we used for surveillance. In the recent paper by Davila et al from the Surveillance, Epidemiology, and End-Results registry Medicare database, when abdomen computed tomography or magnetic resonance imaging were considered as surveillance tests irrespective of intent, the surveillance prevalence increased to 46.3%.3Davila J.A. Morgan R.O. Richardson P.A. et al.Use of surveillance for hepatocellular carcinoma among patients with cirrhosis in the United States.Hepatology. 2010; 52: 132-141Crossref PubMed Scopus (292) Google Scholar We agree that there is a need for increased identification of those at risk for HCC; improvements in the evidence base for the use of biomarkers, ultrasonography, and other cost-effective screening methods; and wider application of surveillance of the at-risk population. In addition, Dr Braillon also raises the issue of age at HCC diagnosis in the surveillance and nonsurveillance groups and the possibility that patients under surveillance are diagnosed and die younger than patients not under surveillance. In the majority of studies summarized in a recent publication, the ages of patients with HCC detected during surveillance were not different from the ages of patients with HCC detected without surveillance.4Yang J.D. Kim W.R. Surveillance for hepatocellular carcinoma in patients with cirrhosis.Clin Gastroenterol Hepatol. 2011 June 13; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (173) Google Scholar In fact, in one study, the mean age of patients with HCC detected during surveillance was older than that of patients with HCC detected without surveillance.5Tong M.J. Sun H.E. Hsien C. et al.Surveillance for hepatocellular carcinoma improves survival in Asian-American patients with hepatitis B: results from a community-based clinic.Dig Dis Sci. 2010; 55: 826-835Crossref PubMed Scopus (35) Google Scholar The mean age in the surveillance group (62 years old) was similar to that in the nonsurveillance group (63 years old) in our study population, and the effect of surveillance on patient survival was essentially unchanged after adjusting for age. Although evidence from randomized controlled trials would be ideal, it has been argued that this is not feasible, as the benefit of surveillance is well established not only among physicians but also among patients.6Poustchi H. Farrell G. Strasser S. et al.Feasibility of conducting a randomised control trial for liver cancer screening: Is a randomized controlled trial for liver cancer screening feasible or still needed?.Hepatology. 2011 July 28; ([Epub ahead of print])Crossref PubMed Scopus (107) Google Scholar Instead, there is good evidence that surveillance increases the rate of early detection of HCC and thus allows patients to receive potentially curative treatment, thus increasing survival.4Yang J.D. Kim W.R. Surveillance for hepatocellular carcinoma in patients with cirrhosis.Clin Gastroenterol Hepatol. 2011 June 13; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (173) Google Scholar For this reason, the American Association for the Study of Liver Disease recommends HCC surveillance in patients who are at increased risk for HCC.7Bruix J. Sherman M. AASLD practice guideline, management of hepatocellular Carcinoma: an update.2010http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/HCCUpdate2010.pdfGoogle Scholar We agree that primary prevention of HCC by vaccinating against HBV, decreasing alcohol intake, cessation of smoking, avoiding new viral hepatitis infections through patient education, and avoidance of iatrogenic infections by the use of universal precautions in health care facilities are of utmost importance.8Yang J.D. Roberts L.R. Hepatocellular carcinoma: a global view.Nat Rev Gastroenterol Hepatol. 2010; 7: 448-458Crossref PubMed Scopus (1035) Google Scholar At the same time, identifying the at-risk population and implementing HCC surveillance is another important step towards improving the dismal prognosis of patients with HCC. Hepatocellular Carcinoma: Still in Search of Evidence-Based CareClinical Gastroenterology and HepatologyVol. 10Issue 2PreviewDear Editor: Full-Text PDF