Not that strong. The AASLD guidelines for hepatocellular carcinoma (HCC) have faced additional scrutiny and an editorial reviews the basis for HCC screening recommendations (Hepatology 2012; 56: 793-96).
According to the authors, there have been two randomized controlled trials of HCC screening in China. One that did not demonstrate benefits of HCC screening relied on resection as the treatment for early-stage HCC. However, a large proportion of those with screen-detected HCC did not undergo resection.
The second trial demonstrated benefit but had several issues. First, the statistical analysis has been criticized as faulty due to the cluster randomization method while analyzing with an individual patient basis method. In addition, most North American cases of HCC are related to HCV rather than HBV; thus, the results may not be applicable.
The editorial counters that there are additional lines of evidence that HCC screening is effective for HCV and that an adequate RCT in this country will never be feasible. Specifically, they suggest that an adequate study would need 10,000 subjects. This would be further complicated by informed consent; an Australian study has shown that 90% of patients would refuse randomization and prefer to undergo screening.
The editorial points out that advancement in treatments have lowered the likelihood of morbidity in patients identified through screening as well.
As part of their conclusion, the authors quote Sir Austen Bradford Hill who conducted the first RCT in humans: All scientific work is incomplete…liable to be upset by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have, or to postpone the action it appears to demand at a given time.”
Related blog entry:
- -Ann Intern Med 2012; 156: 387-89. HCC screening -‘a rush to judgement’
- -Hepatology 2011; 53: 1020-22. AASLD HCC guideline update. Management of Hepatocellular Carcinoma – AASLD