Hepatocellular carcinoma surveillance in Australia: current and future perspectives

IF 6.7 2区 医学 Q1 MEDICINE, GENERAL & INTERNAL Medical Journal of Australia Pub Date : 2024-09-08 DOI:10.5694/mja2.52441
Alain Braillon
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Abstract

To the Editor: Hui and colleagues must be commended for underscoring that a program with centralisation should be a cornerstone for hepatocellular carcinoma (HCC) surveillance.1 Indeed, with funding for quality assurance, it allows for monitoring of uptake to guarantee effectiveness and equitability. However, their narrative review deserved robust comments.

Firstly, the prerequisite for screening is a positive benefit to harm ratio and the highlighting of a positive randomised trial of patients from China should not have masked its major flaws and that another trial was negative.2, 3 Similarly, stating that “observational studies are inherently limited, given the potential for lead-time and length-time biases to overestimate survival benefit”1 is a euphemism.

Further, the diagnosis of small nodules (< 2 cm) in a cirrhotic liver with fibrous septa and regenerative nodules is a complex issue requiring multiple investigations and, frequently, a biopsy.

Secondly, the analysis of the poor uptake of screening is wise4 but it should not have ignored that there is no consensus among national recommendations: neither for imaging techniques and the serum biomarkers, nor for their combination and frequency. Rather than including a table comparing recommendations for group surveillance among national recommendations (Box 2 in Hui et al1), the authors should have included a table summarising the profusion of screening methods; having so many methods suggests that none are adequate.

Lastly, Hui and colleagues should not have ignored the warnings from the US National Cancer Institute summarising the evidence for benefits and harms of HCC screening: “Based on fair evidence, screening of persons at elevated risk does not result in a decrease in mortality from hepatocellular cancer” and “Good evidence for uncommon but serious harms”.5 At least Hui and colleagues should have recalled that the Gastroenterological Society of Australia must be commended as none of its four recommendations related to surveillance of HCC are graded A1.6

The recommendation for screening for HCC by some professional organisations, despite lack of evidence for a positive benefit to harm ratio on relevant clinical outcomes from randomised trials, is an exception in medicine. Exceptions in medicine rarely benefit patients.

No relevant disclosures.

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澳大利亚的肝细胞癌监测:当前和未来展望。
致编辑:Hui 及其同事强调了集中管理的项目应成为肝细胞癌 (HCC) 监测的基石,这一点必须得到赞扬。首先,筛查的先决条件是积极的利弊比,强调一项针对中国患者的积极随机试验不应掩盖其重大缺陷,也不应掩盖另一项试验是消极的、3 同样,"观察性研究本身就有局限性,因为前导时间和时间长度偏差可能会高估生存获益 "1 的说法也是委婉的。此外,肝硬化患者肝内有纤维间隔和再生结节的小结节(< 2 cm)的诊断是一个复杂的问题,需要进行多项检查,并经常需要进行活检。其次,对筛查覆盖率低的分析是明智的4 ,但不应忽视各国的建议尚未达成共识:无论是成像技术和血清生物标志物,还是它们的组合和频率。最后,Hui 及其同事不应忽视美国国家癌症研究所(US National Cancer Institute)总结 HCC 筛查利弊证据时提出的警告:"5 至少 Hui 及其同事应该记得,澳大利亚胃肠病学会(Gastroenterological Society of Australia)必须受到表扬,因为该学会提出的与监测 HCC 相关的四项建议中没有一项被评为 A1 级。6 尽管缺乏证据表明随机试验的相关临床结果具有积极的利弊比,但一些专业组织仍建议进行 HCC 筛查,这在医学界属于例外情况。医学界的例外情况很少会使患者受益。
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来源期刊
Medical Journal of Australia
Medical Journal of Australia 医学-医学:内科
CiteScore
9.40
自引率
5.30%
发文量
410
审稿时长
3-8 weeks
期刊介绍: The Medical Journal of Australia (MJA) stands as Australia's foremost general medical journal, leading the dissemination of high-quality research and commentary to shape health policy and influence medical practices within the country. Under the leadership of Professor Virginia Barbour, the expert editorial team at MJA is dedicated to providing authors with a constructive and collaborative peer-review and publication process. Established in 1914, the MJA has evolved into a modern journal that upholds its founding values, maintaining a commitment to supporting the medical profession by delivering high-quality and pertinent information essential to medical practice.
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