Hepatocellular carcinoma surveillance in Australia: current and future perspectives

In reply: On behalf of my co‐authors, I thank Braillon for their interest in our article.1 As highlighted by Braillon,2 we accept there are some methodological limitations in the 2004 trial that investigated hepatocellular carcinoma (HCC) surveillance in Chinese hepatitis B patients with or without cirrhosis.3 Braillon also refers to an additional negative trial for HCC surveillance. We assume this is in reference to the study by Chen and colleagues, which found surveillance resulted in earlier HCC diagnosis but without a reduction in overall mortality.4 However, this trial was based on α‐fetoprotein‐only screening in Chinese hepatitis B patients between 1989 and 1995. These results cannot be generalised to modern clinical practice, given the considerable paradigm shift in surveillance, diagnosis and treatment over the past three decades.

In the absence of additional randomised trials, Braillon has shown that there remains some debate about the overall value of HCC surveillance. Further randomised trials are, however, unlikely to be practical or ethically feasible, given surveillance is a well established standard of care worldwide. A systematic review of contemporary observational data has found that HCC surveillance in cirrhotic patients results in early detection and improved survival due to curative treatment receipt, although the incidence and magnitude of surveillance‐related harm is less well studied.5

Given HCC surveillance is an established standard of care in high risk patients, we feel there is merit in a centralised surveillance program. Beyond improving access and uptake, centralisation will provide high quality prospective data that can assess the real‐world benefit and harms of surveillance in Australia.

HCC is an emerging and costly public health problem in many Western countries that remains under‐recognised. An important tenet of public health is the prioritisation of preventive care. In the case of HCC, we argue that an increased focus on its primary and secondary prevention presents the greatest opportunity for improving outcomes for this devastating disease.