An Assessment of Benefits and Harms of Hepatocellular Carcinoma Surveillance in Patients With Cirrhosis
An Assessment of Benefits and Harms of Hepatocellular Carcinoma Surveillance in Patients With Cirrhosis
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DOI：
10.1002/hep.28895
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发表时间：
2017-04-01
期刊：
影响因子：
13.5
通讯作者：
Singal, Amit G.
中科院分区：
文献类型：
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作者：
Atiq, Omair;Tiro, Jasmin;Singal, Amit G.
虽然监测超声和甲胎蛋白（AFP）检测的直接危害极小，但在确定肝细胞癌（HCC）筛查项目的价值时，必须权衡后续检测带来的不良影响与监测的益处。我们研究的目的是描述接受HCC监测的肝硬化患者中监测益处和危害的发生率以及相关因素。我们对2010年7月至2013年7月在一个安全网医疗系统中接受随访的肝硬化患者进行了一项回顾性队列研究。我们记录了与监测相关的益处，定义为早期肿瘤检测和治愈性治疗，以及与监测相关的身体伤害，定义为因假阳性或不确定的监测结果而进行的计算机断层扫描（CT）或磁共振成像（MRI）扫描、活检或其他操作。使用多变量逻辑回归评估监测危害的社会人口学和临床相关因素。我们确定了680例肝硬化患者，其中78例（11.5%）在3年研究期间发生了HCC。在通过监测发现的48例（61.5%）HCC中，43.8%通过超声检测到，31.2%通过AFP检测到，25.0%通过两种监测检测方法均检测到。监测发现的患者早期HCC的比例更高（70.2%对40.0%；P = 0.009），超声检测和AFP检测到的肿瘤在肿瘤分期上没有差异（P = 0.53）。187例（27.5%）患者出现了与监测相关的身体伤害，超声相关伤害的比例高于AFP相关伤害（22.8%对11.4%；P < 0.001）。与监测相关的危害与谷丙转氨酶（ALT）升高（比值比[OR]，1.87；95%置信区间[CI]，1.26 - 2.76）、血小板减少症（OR，2.06；95%CI，1.26 - 3.38）以及肝病专科护理（OR，1.63；95%CI，1.09 - 2.42）有关。结论：超过四分之一的肝硬化患者因假阳性或不确定的监测检测而遭受身体伤害——超声相关的情况比AFP相关的更为常见。需要采取干预措施来减少与监测相关的危害，以提高HCC筛查项目在临床实践中的价值。
Although surveillance ultrasound and alpha fetoprotein (AFP) tests have minimal direct harm, downstream harms from follow-up tests must be weighed against surveillance benefits when determining the value of hepatocellular carcinoma (HCC) screening programs. Our study's aims were to characterize prevalence and correlates of surveillance benefits and harms in cirrhosis patients undergoing HCC surveillance. We conducted a retrospective cohort study among patients with cirrhosis followed at a safety-net health system between July 2010 and July 2013. We recorded surveillance-related benefits, defined as early tumor detection and curative treatment, and surveillance-related physical harms, defined as computed tomography or magnetic resonance imaging scans, biopsies, or other procedures performed for false-positive or indeterminate surveillance results. Sociodemographic and clinical correlates of surveillance harms were evaluated using multivariable logistic regression. We identified 680 patients with cirrhosis, of whom 78 (11.5%) developed HCC during the 3-year study period. Of the 48 (61.5%) HCCs identified by surveillance, 43.8% were detected by ultrasound, 31.2% by AFP, and 25.0% by both surveillance tests. Surveillance-detected patients had a higher proportion of early HCC (70.2% vs. 40.0%; P = 0.009), with no difference in tumor stage between ultrasound-and AFP-detected tumors (P = 0.53). Surveillance-related physical harms were observed in 187 (27.5%) patients, with a higher proportion of ultrasound-related harm than AFP-related harm (22.8% vs. 11.4%; P < 0.001). Surveillance-related harms were associated with elevated ALT (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.26-2.76), thrombocytopenia (OR, 2.06; 95% CI, 1.26-3.38), and hepatology subspecialty care (OR, 1.63; 95% CI, 1.09-2.42). Conclusion: Over one fourth of patients with cirrhosis experience physical harm for false-positive or indeterminate surveillance tests-more often related to ultrasound than AFP. Interventions are needed to reduce surveillance-related harm to increase the value of HCC screening programs in clinical practice.