Dr Amit Singal on Populations at Risk for HCC and When Screening Is Needed

Amit Singal, MD, medical director of the Liver Tumor Program and chief of hepatology at UT Southwestern Medical Center, discusses populations at the highest risk of hepatocellular carcinoma (HCC), when screening is needed, and key tools in HCC surveillance and screening.

Transcript

What populations are at the highest risk for HCC, and when should patients be screened?

We have identifiable patient populations that have a very high risk for HCC. One of the most common globally is the presence of chronic hepatitis B, and there are high-risk subgroups of those with chronic hepatitis B. We used to define those using demographics—for example, older male, older female—but we've now moved into risk calculators that nicely capture several of these different factors.

One of the best validated risk calculators among those with chronic hepatitis B is something called the PAGE-B score, which incorporates platelet count, age, gender, and then gives you a score that's a continuous nature. If you have a score of 10 or greater, you have a sufficiently high risk of HCC that you warrant HCC screening. In the Western world, it's moreso the presence of underlying cirrhosis, and that can be due to any one of several different etiologies, whether that's viral hepatitis, or nonviral etiologies. The common viral hepatitis etiologies are chronic hepatitis B and chronic hepatitis C. And then the most common nonviral etiologies include alcohol, and something that used to be called nonalcoholic fatty liver disease and is now called metabolic dysfunction–associated steatotic liver disease, or MASLD for short.

Prevention and surveillance in HCC have been focuses of your research. What are some of the key tools in both of these areas that clinicians should be implementing?

When we think of prevention, I think it really goes back to those underlying etiologies. From a prevention perspective, it's identifying those with chronic viral hepatitis and treating them appropriately. So, for many patients with chronic hepatitis B, we have very effective medications that can suppress the chronic hepatitis B and significantly reduce the risk of developing HCC. For those who have chronic hepatitis C, we have very efficacious regimens, which can now cure you from hepatitis C with very short treatment regimens of 2 to 3 months.

When we think through either alcohol-related liver disease or metabolic dysfunction–associated liver disease, we can also counsel our patients on either alcohol abstinence or at least sort of minimizing alcohol use. And then for those with metabolic dysfunction, we can work with our patients on weight loss, control of the the metabolic syndrome, including diabetes, which can also reduce the risk of liver disease progression and the risk of HCC.

I think when we think of this, it goes back to that Ben Franklin adage: An ounce of prevention is worth a pound of cure.vI think that's really where we need to spend a lot of our efforts is prevention of chronic liver disease and prevention of HCC.

When we think through screening, or secondary prevention, we also have good strategies that we can implement in those at-risk individuals who have already progressed to chronic hepatitis B or the presence of cirrhosis. We typically recommend semiannual surveillance using abdominal ultrasound with or without a blood test called alpha fetoprotein. When we have those patients, it's important for us as clinicians to identify those patients, discuss the risk of HCC, and then to routinely do this every 6 months.