Hepatocellular carcinoma surveillance in Australia: current and future perspectives

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 (<2cm) 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.