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HCC Screening in Patients With Chronic HBV Infection: No Room for Error

Steven L. Flamm, MD

Chief, Hepatology Program
Professor of Medicine
Medical Director
, Liver Transplantation
Feinberg School of Medicine
Northwestern University
Chicago, Illinois


Steven L. Flamm, MD, has disclosed that he has received consulting fees and funds for research support from Gilead Sciences.


View ClinicalThoughts from this Author

Released: June 16, 2020

Patients with chronic HBV infection are at high risk for hepatocellular carcinoma (HCC)─reported incidences are approximately 1% per year in patients without cirrhosis and approximately 3% per year in patients with cirrhosis. As one of the only liver-related illnesses in which patients without cirrhosis can develop HCC, practitioners must be vigilant in screening patients with chronic HBV infection.

Who Should Be Screened?
At minimum, clinicians should adhere to the AASLD guidelines on screening for HCC. According to the 2018 AASLD guidance, the following individuals are at high risk and should be screened:

  • All patients with cirrhosis
  • Patients with a first-degree family member with history of HCC
  • Asian or black men older than 40 years of age
  • Asian women older than 50 years of age
  • Patients coinfected with hepatitis D virus

The guidance recommends that all patients with chronic HBV infection in these high-risk categories be screened every 6 months via liver ultrasound with or without alpha-fetoprotein (AFP). However, ultrasounds are not onerous, and if patients are willing to get one and have the insurance coverage, I encourage screening in patients who may not fit squarely into one of the high-risk categories outlined in the guidance. This may include younger patients who do not quite meet the age cutoffs or patients with fibrosis but not technically cirrhosis.

Patients who have younger first-degree family members with a history of HCC are at the highest risk. Although I still worry about my patients with first-degree family members who developed HCC at 60 or 70 years of age, I worry less so than if they had a family member who developed HCC at 35 years of age. In my practice, I have also seen my patients develop HCC when there is a strong family history outside of the first-degree family. If a patient tells me that 2 uncles and an aunt all developed HCC, that patient does not technically meet the guidelines—but I would still have heightened concern for this patient compared with a patient with no family history of HCC.

Screening With AFP
Currently, AFP levels are assessed at the discretion of the practitioner. In my practice, I do evaluate AFP in addition to performing a liver ultrasound. It is highly important that practitioners do not miss the development of HCC because if missed, it becomes a terminal disease instead of one that is curable. I find AFP to be helpful because it has been my experience that even mild AFP elevations in patients with chronic HBV infection may indicate HCC development. If the AFP is mildly elevated and the ultrasound is unremarkable, I will request cross-sectional imaging, such as a triphasic CT scan or an MRI, to look for a small lesion that may not be visible on ultrasound.

However, clinicians should keep in mind that if the AFP is normal, that does not rule out HCC. There are many patients with HCC that have a normal AFP—remember that the AFP level is helpful in detecting HCC if it is elevated, but a normal AFP does not provide much useful information.

Your Thoughts?
What is your current practice for HCC screening? Please answer the polling question and share your thoughts in the comments section below.

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