There is a “strikingly low adherence” to clinical guidelines
for ultrasound screening for hepatocellular carcinoma in Western Europe, researchers
report in the Journal of Viral Hepatitis.
Over years or decades, chronic hepatitis B or C can cause
serious liver disease including both cirrhosis and liver cancer (hepatocellular
carcinoma, HCC). The risk of HCC is elevated in people with cirrhosis and also in
people with hepatitis/HIV co-infection.
HCC treatment is more likely to be successful if the cancer
is diagnosed promptly. Clinical guidelines from the European Association for
the Study of the Liver (EASL), American Association for the Study of Liver
Diseases (AASLD) and European AIDS Clinical Society (EACS) therefore all
recommend that adults with cirrhosis should be screened with ultrasound scans
for HCC every six months.
Although the screening interval is the same, regardless of
co-infection, previous US studies have shown low adherence to the guideline,
with between 13 and 51% of people with hepatitis mono-infection screened every
Dr Sophie Willemse and colleagues pooled data from the Collaboration
of Observational HIV Epidemiological Research in Europe (COHERE). Their aim was
to assess compliance with HCC screening guidelines in a large European cohort
of HIV-positive patients with hepatitis B or C co-infection and cirrhosis.
A total of 646 people were included in the analysis, with
data collected between 2005 and 2015. Only the four participating cohorts which
routinely record document ultrasound results were included, reflecting practice
in the Netherlands, France, Austria and Italy.
Participants had co-infection with hepatitis B (13%),
hepatitis C (80%) or both (7%). They had been diagnosed with cirrhosis for a
median of five years and 93% were taking antiretroviral therapy. Probable HIV
transmission routes were injecting drug use (57%), sex between men (20%) and
sex between men and women (12%).
The proportion of participants screened within the previous
six months varied between 5.4% in 2005, 18.4% in 2008 and 14.2% in 2014.
Figures for screening within the previous twelve months were
not much better: 7%, 26% and 30% respectively.
There was better adherence to guidelines for patients with
more frequent clinic visits. Those diagnosed with cirrhosis for a longer period
of time had somewhat better screening, possibly reflecting a more stable
situation where both patient and clinician are aware of the importance of
The authors say multiple factors may contribute, including
limited clinician awareness of guidelines and the absence of systems to
schedule and follow-up screening visits. “This finding warrants urgent action
to ensure better implementation of HCC screening guidelines,” they say.