Using serum α-fetoprotein for prognostic prediction in patients with hepatocellular carcinoma: what is the most optimal cutoff?
OBJECTIVE
The prognostic ability of α-fetoprotein (AFP) for patients with hepatocellular carcinoma (HCC) was examined by using different cutoff values. The optimal AFP cutoff level is still unclear.


METHODS
A total of 2579 HCC patients were consecutively enrolled in Taiwan, where hepatitis B is the major etiology of chronic liver disease. Four frequently used AFP cutoff levels, 20, 200, 400, 1000 ng/mL, were investigated. One-to-one matched pairs between patients having AFP higher and lower than the cutoffs were selected by using the propensity model. The adjusted hazard ratios of survival difference were calculated with Cox proportional hazards model.


RESULTS
Patients with a higher AFP level were associated with more severe cirrhosis, more frequent vascular invasion, higher tumor burden and poorer performance status (all p<0.0001). In the propensity model, 4 groups of paired patients were selected, and there was no difference found in the comparison of baseline characteristics (all p>0.05). Patients with AFP <20 ng/mL had significantly better long-term survival than patients with AFP ≧20 ng/mL (p<0.0001), and patients with AFP <400 ng/mL had significantly better overall outcome than patients with AFP ≧400 ng/mL (p = 0.0186). There was no difference of long-term survival between patients divided by AFP levels of 200 and 1000 ng/mL. The adjusted hazard ratios of AFP ≧20 ng/mL and AFP ≧400 ng/mL were 1.545 and 1.471 (95% confidence interval: 1.3-1.838 and 1.178-1.837), respectively.


CONCLUSIONS
This study shows the independently predictive ability of baseline serum AFP level in HCC patients. AFP levels of 20 and 400 ng/mL are considered feasible cutoffs to predict long-term outcome in unselected HCC patients.
Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Biostatistics, University of California Los Angeles, Los Angeles, California, United States of America.
Chia-Yang
CY
Hsu
Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Po-Hong
PH
Liu
Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Yun-Hsuan
YH
Lee
Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.
Cheng-Yuan
CY
Hsia
Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Yi-Hsiang
YH
Huang
Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Han-Chieh
HC
Lin
Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.
Yi-You
YY
Chiou
Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Fa-Yauh
FY
Lee
Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Institute of Pharmacology, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Teh-Ia
TI
Huo
D001774:Blood Chemical Analysis / Q000592:standards*; D006528:Carcinoma, Hepatocellular / Q000097:blood* / Q000175:diagnosis*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000097:blood* / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D057216:Propensity Score; D012015:Reference Standards; D016019:Survival Analysis; D000509:alpha-Fetoproteins / Q000378:metabolism*
D000509:alpha-Fetoproteins