Hepatocellular carcinoma surveillance in Australia: current and future perspectives

To the Editor: We read with interest the excellent review by Hui and colleagues1 on hepatocellular carcinoma (HCC) surveillance in Australia. HCC is increasing in incidence in Australia, and is often diagnosed late, when curative options are limited and mortality rates are high.1 Surveillance is recommended in high risk individuals but uptake is suboptimal; a centralised surveillance program may provide an improved model of care delivery.1 However, screening programs may only be successful in those with a diagnosis of a condition that increases their risk of HCC.

Improved case‐finding strategies are recommended;1 however, an important group not discussed in this article is pregnant people. This is a unique population who is universally tested for hepatitis B in Australia,2 and who is often interacting with the health care system for the first time at a young age, without other comorbid conditions. In those at high risk of progression to HCC, such as women from sub‐Saharan Africa aged over 20 years, antenatal diagnosis provides an opportunity for education. Linkage to specialist care during pregnancy also enables the development of an HCC surveillance plan to maximise the opportunities for early diagnosis of complications.

There is evidence to suggest that, in Australia, people who are diagnosed during pregnancy with a medical condition that is associated with long term complications, such as gestational diabetes3 and hypertensive disorders in pregnancy,4 often do not engage in recommended follow‐up care in the postpartum period. Postpartum retention in care in those with hepatitis B in Australia is poorly documented, but appears similar to other antenatally diagnosed conditions, with existing data estimating that less than half engage with hepatitis B care during the first year postpartum.5 In addition to the barriers to accessing surveillance outlined by Hui and colleagues,1 engagement in care during the postpartum period may be hampered by the need to juggle family and child care responsibilities, return to the workforce, and access to child care to allow attendance at appointments.

We recommend integrating existing antenatal screening and diagnosis into strategies to identify those at high risk who may benefit from HCC surveillance, and optimising postpartum pathways of care to support these individuals.