Australian recommendations for the management of hepatocellular carcinoma

In reply: We welcome the comments raised by Braillon1 regarding the contribution of smoking to the risk of hepatocellular carcinoma (HCC).

We have the following comments. Firstly, the Australian recommendations for the management of HCC are a consensus statement developed by multiple stakeholders representing peak organisations. In addition to hepatologists, oncologists, palliative care physicians, radiologists and surgeons produced the statement.2 The full list of contributors is listed in the acknowledgement section.

Secondly, due to journal limitations on space, the published article focused on the most significant issues relating to the diagnosis and management of HCC and provided context for the listed recommendations. Smoking is a modifiable contributor to HCC development, and the published manuscript highlights the importance of smoking cessation in Box 3 (where smoking cessation is listed as a modifiable risk factor) and Box 6.2

Thirdly, the health impacts of smoking are not disputed. Fortunately, between 1991 and 2019, the proportion of daily smokers in Australia has halved.3 While smoking is likely to have a negative impact on HCC, this has not been demonstrated in prospective controlled studies and currently does not appear in any risk calculators. This is in part due to the quality of evidence, which is largely derived from epidemiological cohort studies that may be vulnerable to confounding variables such as socio‐economic factors, including alcohol use, and the known association of smoking with advanced hepatic fibrosis.4 Despite the lack of high level evidence, our position is to advocate smoking cessation in any individual at risk from HCC.

Lastly, consensus statements by their very nature cover topics less well studied, and provide expert clinician input using Delphi methodology to synthesise sparse or conflicting data with the purpose of providing practical guidance.5,6 It is therefore not surprising that nine of the recommendations are derived from level A evidence. Although only four recommendations focus on surveillance, the accompanying Box 2 and Box 3 provide additional details on this topic for the reader.

The authors’ aim was to raise awareness and provide an overview of the important aspects of HCC management to the general readership of the MJA. We are very grateful for Braillon’s comments in highlighting the issue of smoking in patients at risk from and diagnosed with HCC.