Impact of disease stage and aetiology on survival in hepatocellular carcinoma: implications for surveillance

Abstract

Background: Variation in survival in hepatocellular carcinoma (HCC) has been attributed to different aetiologies or disease stages at presentation. While international guidelines recommend surveillance of high-risk groups to permit early diagnosis and curative treatment, the evidence that surveillance decreases disease-specific mortality is weak.

Methods: We compared HCC survival figures from Japan (n=1174) and Hong Kong (n=1675) over similar time periods (Japan 2000-2013, Hong Kong, China 2003-2014). The former has an intensive national surveillance programme, while the latter has none. We also analysed changes in survival in Japan over a 50-year period including data from before and after institution of a national HCC surveillance programme.

Results: In Japan, over 75% of cases are currently detected by surveillance, whereas in Hong Kong <20% of cases are detected presymptomatically. Median survival was 52 months in Japan and 17.8 months in Hong Kong; this survival advantage persisted after allowance for lead-time bias. Sixty-two per cent of Japanese patients had early disease at diagnosis and 63% received curative treatment. The comparable figures for Hong Kong were 31.7% and 44.1%, respectively. These differences could not be accounted for by disease aetiology, and patients in Hong Kong who were detected at an early stage had a similar survival to the analogous patients in Japan.

Conclusions: The variation in survival is largely accounted for by stage at diagnosis, which in turn relates to the intensity of surveillance programmes and the consequent variation in curative therapeutic options.

Figure 1

Kaplan–Meier curves showing survival. (A) In the Japanese and Chinese cohorts, (B) in the Japanese and Chinese cohorts after lead-time bias, (C) in Japanese and Chinese patients who were within the Milan criteria, (D) in Japanese and Chinese patients who were within the Milan Criteria and Child–Pugh A, (E) in Japan over the decades (1966–1979, 1980–1989, 1990–1999 and 2000–2013) and (F) survival according to screening status (after lead-time bias adjustment) in the Japanese (and Chinese) cohorts.