title: Application of hepatocellular carcinoma surveillance in a European setting. What can we learn from clinical practice?
abstract: OBJECTIVE
  Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is recommended in clinical guidelines. In real-life management, surveillance rates below 20% have been reported from the United States. We aimed to determine the use of HCC-surveillance in patients diagnosed with HCC in a European setting, and to identify the reasons for surveillance failures.
  
  
  METHODS
  Age, gender, tumour characteristics, BCLC classification, Child-Pugh stage, pre-existing liver disease, treatment, survival, frequency of HCC surveillance and reasons for surveillance failures were retrospectively determined in 616 patients diagnosed with HCC at Karolinska University Hospital 2005-2012.
  
  
  RESULTS
  Hepatitis C, alcoholic liver disease and non-alcoholic fatty liver disease (NAFLD) were the most common diagnoses. The proportion of HCC patients diagnosed through surveillance was 22%. In 35% of cases, surveillance was missed due to doctor's failure to order surveillance or to diagnose the underlying liver disease. Diagnosis of NAFLD or alcoholic liver disease increased the risk of not receiving surveillance more than two-fold. Undiagnosed liver disease was most common in NAFLD patients. Patients who underwent surveillance had smaller tumours, more frequently received curative treatment, and had better survival compared to those in whom surveillance was indicated but missed.
  
  
  CONCLUSIONS
  In a European setting, only 22% of HCCs were diagnosed by surveillance, and in more than one-third of cases, surveillance was indicated but missed. NAFLD and alcoholic liver disease were associated with deficient surveillance. Survival was significantly better in patients who underwent surveillance compared with those in whom surveillance was missed although indicated.
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Pia
authors.initials: P
authors.lastname: Edenvik
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Loa
authors.initials: L
authors.lastname: Davidsdottir
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Antti
authors.initials: A
authors.lastname: Oksanen
authors.affiliation: Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Bengt
authors.initials: B
authors.lastname: Isaksson
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Rolf
authors.initials: R
authors.lastname: Hultcrantz
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Per
authors.initials: P
authors.lastname: Stål
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy; D005260:Female; D006526:Hepatitis C / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy; D006785:Hospitals, University; D006801:Humans; D053208:Kaplan-Meier Estimate; D008108:Liver Diseases, Alcoholic / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy; D008113:Liver Neoplasms / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy; D008297:Male; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy; D011159:Population Surveillance; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013548:Sweden / Q000453:epidemiology; D013997:Time Factors; D047368:Tumor Burden
keywords: hepatocellular carcinoma; non-alcoholic fatty liver disease; real-life management; surveillance