Overdiagnosis of hepatocellular carcinoma: Prevented by guidelines?

Abstract

Overdiagnosis refers to detection of disease that would not otherwise become clinically apparent during a patient's lifetime. Overdiagnosis is common and has been reported for several cancer types, although there are few studies describing its prevalence in HCC surveillance programs. Overdiagnosis can have serious negative consequences including overtreatment and associated complications, financial toxicity, and psychological harms related to being labeled with a cancer diagnosis. Overdiagnosis can occur for several different reasons including inaccurate diagnostic criteria, detection of premalignant or very early malignant lesions, detection of indolent tumors, and competing risks of mortality. The risk of overdiagnosis is partly mitigated, albeit not eliminated, by several guideline recommendations, including definitions for the at-risk population in whom surveillance should be performed, surveillance modalities, surveillance interval, recall procedures, and HCC diagnostic criteria. Continued research is needed to further characterize the burden and trends of overdiagnosis as well as identify strategies to reduce overdiagnosis in the future.

Figure 1.

Schema of overdiagnosis and lead time in patients with hepatocellular carcinoma

Figure 2.

Overdiagnosis due to indolent tumor growth patterns and competing risk of mortality

Figure 3.

Effect of overdiagnosis on cancer incidence In the absence of overdiagnosis (left panel), there is an increase in cancer incidence during the screening period, which is then compensated with decreased incidence after screening is stopped. In the setting of overdiagnosis (right panel), there is an increased incidence but no associated decreased incidence after screening cessation.