For people with chronic hepatitis B, authoritative guidelines recommend a liver ultrasound every 6 months and a blood test for alpha fetoprotein (AFP) to monitor for hepatocellular carcinoma that may be caused by hepatitis B virus infection.
Despite this, there are still some chronic hepatitis B patients who fail to detect early liver cancer in time and are in the middle to late stages when it is detected!
Why is this the case? What patients with chronic hepatitis B are more likely to have this condition? What can be done to address the issue of test failure? This article takes a look at a newly published study to answer these questions.
How was this study conducted?
The study was conducted at two universities in Korea.
The study was conducted at two university hospitals in Korea and was a retrospective cohort study in which investigators first took case data from 6503 patients with chronic hepatitis B who were admitted from 2006 to 2011 with good liver function and were screened for the following conditions:
- Able to maintain liver B-ultrasound and methemoglobin at least once every 6 months;
- These tests were normal within 6 months prior to the diagnosis of hepatocellular carcinoma.
Patients with chronic hepatitis B who eventually developed hepatocellular carcinoma were screened and staged using BCLC criteria. Patients with intermediate and advanced stages were considered test failures and were compared with patients diagnosed with early stage hepatocellular carcinoma and statistically analyzed for multiple pairs of factors including age, diabetes, platelet count, methemoglobin level, combined cirrhosis, and liver stiffness.
What are the key findings of this study?
The study’s main findings were
Finally, 4590 patients with chronic hepatitis B who met these requirements were screened, with a mean follow-up time of 73.4 months. Hepatocellular carcinoma occurred in 169 (or 3.7%), including 134 cases of early-stage hepatocellular carcinoma and 15 and 20 patients with intermediate and late stage hepatocellular carcinoma, respectively, once detected.
What percentage of chronic hepatitis B will fail the test?
The analysis showed that for all people with chronic hepatitis B who were routinely tested for liver cancer, the failure rate for liver cancer detection was 0.8% (35/4590). This result tells us that even with adherence to liver B-ultrasound and blood fetoprotein testing every 6 months, 0.8% of patients with chronic hepatitis B will fail liver cancer detection.
This is not a high rate.
This is not a high rate, and when looking at the total number of tests, only 1 in 1000 ultrasound + blood fetoprotein tests is a false negative (the proportion of subjects who have had liver cancer but whose test results do not show it). Despite this, failure to detect liver cancer is still a problem that deserves attention.
What are the factors influencing failure to test for chronic hepatitis B?
The analysis showed that patients with chronic hepatitis B with cirrhosis, methemoglobin over 9ng/mL, liver stiffness values over 11.7kPa, and diabetes had a significantly higher cumulative incidence of failed hepatocellular carcinoma detection (especially at 5 years and beyond).
What are the implications of this study?
The purpose of the test is to detect hepatitis B at an early stage.
The purpose of testing is to detect liver cancer early and gain valuable time for treatment. This study showed that ultrasound + blood fetoprotein detected most early liver cancers, but 20.7% of patients with liver cancer had intermediate to advanced liver cancer by the time of initial diagnosis.
The reasons for this are twofold:
- The accuracy of the B-ultrasound+blood methemoglobin test protocol is not sufficient and the false-negative rate is high;
- Some patients with hepatocellular carcinoma progressed too rapidly, from none to intermediate to advanced stages in a period of 6 months.
For the former, switching to more accurate CT, MRI, etc. may be an option, but these tests are expensive and take a long time to perform; for the latter, a shorter detection period has been suggested, but the same problem occurs, significantly increasing the time and money spent by the patient, too poorly cost-effective, and there is no guarantee that both of these conditions exist at the same time.
The significance of this study is that it shows us a more feasible option for the possible failure of chronic hepatitis B liver cancer testing, which is to adjust liver cancer testing appropriately based on the presence or absence of factors that may cause liver cancer testing failure in patients, in addition to the routine 6-monthly B-ultrasound + blood methemoglobin.
Specifically, for patients with chronic hepatitis B who have cirrhosis, methemoglobin over 9ng/mL, liver stiffness values over 11.7kPa, or combined diabetes, increase the frequency of liver cancer testing and add more accurate imaging such as CT and MRI if necessary.
In this way, people at low risk of liver cancer detection failure can enjoy the convenience and cost-effectiveness of B ultrasound + blood methotrexate testing, while people at high risk of liver cancer detection failure can reduce the risk of liver cancer detection failure, which is a two-pronged approach.
I hope all chronic hepatitis B patients understand that chronic hepatitis B can develop into liver cancer, and early detection and treatment of liver cancer is the key to a good outcome. So, insisting on regular checkups is the key!