Over a third of
HIV-positive people with hepatitis C virus-related liver cirrhosis are
not having regular ultrasound examinations to check for possible liver cancer,
Canadian research published in Clinical
Infectious Diseases shows.
Two patients diagnosed with hepatocellular
carcinoma (HCC, liver cancer) did not have ultrasound screens.
receiving care at centres with standardised systems for screening were
significantly more likely to have an abdominal ultrasound.
protocols with automated reminders may be a particularly effective means of
ensuring compliance with screening,” suggest the investigators.
There is a high
prevalence of hepatitis C virus (HCV) co-infection among people with HIV. Liver disease is now an
important cause of death in these individuals. An ever-increasing proportion of
these deaths is caused by HCC.
Canada, Europe and the United States recommend that people with HCV-related
liver cirrhosis should be screened every six to twelve months for HCC using
investigators caring for people co-infected with HIV and HCV wanted to see if
this guidance was being followed. They therefore
designed a prospective study involving co-infected adult patients with
confirmed or possible liver cirrhosis who received care at 16 centres across
Canada between 2003 and 2012.
collected information on whether an abdominal ultrasound was done for each
patient. The investigators examined the participants’ demographic data and clinical
records to see if any factors were associated with an increased chance of having
population comprised 144 people with documented cirrhosis and 220 individuals
with possible cirrhosis (the presence of biomarkers showing serious hepatic
During a median of
2.5 years of follow-up, participants with documented cirrhosis had a mean of 0.6
abdominal ultrasounds each year. Well over a third of participants (36%) with
confirmed cirrhosis never had an ultrasound.
The frequency of examinations for participants with at least one screening
was a mean of one ultrasound per year.
The overall mean
frequency of abdominal ultrasound screening for participants with possible cirrhosis
was 0.4 investigations per year. During 2.4 years of follow-up, 50% of participants
with possible cirrhosis never had an abdominal ultrasound. The mean frequency
of monitoring for those who did have this test was 0.7 investigations per year.
“More than one
third of patients with documented or possible cirrhosis did not undergo
appropriate screening for hepatocellular carcinoma with ultrasoundography
during the course of their follow-up,” comment the authors. “The infrequent
performance of ultrasounds in the group with possible cirrhosis in particular
suggests that patients at risk of advanced liver disease may not be recognized
and diagnosed as such.”
suggest that a focus on virologic and treatment outcomes in co-infected
individuals could explain why large numbers of patients were never screened: “Given
the importance of virologic control of HIV and treatment of HCV, medical visits
may be focused more on management of these infections, as opposed to the
consequences of liver disease.”
can be severe. A total of nine cases of HCC were diagnosed during follow-up.
Two cases involved patients who had never had an abdominal ultrasound,
suggesting to the investigators “missed opportunities for detecting HCC”.
For the other
participants, there was a long interval between the last ultrasound and HCC
There was a 69%
mortality rate among patients with HCC.
investigators’ first set of analysis, poverty (p = 0.01) and injecting drug use
(p = 0.02) were associated with lower chances of ultrasound screening for
people with confirmed cirrhosis. In contrast, patients were significantly
more likely to be screened if they had alcohol abuse problems or were taking
controlled for potential confounders showed that the only factor associated with
ultrasound screening was the presence of a systematic screening system at the
clinic offering care. Participants receiving care at a centre with such a system
were twice as likely to have an ultrasound compared to people treated at a
hospital without systematic screening (confirmed cirrhosis, OR = 2,20; 95% CI,
1.37-3.53, p = 0.001); possible cirrhosis, OR = 1.96; 95% CI, 1.21-3.16, p =
predictor of having had screening was the presence of a systematic process in
place to schedule and follow screening ultrasounds, usually with the
involvement of a hepatologist,” comment the researchers. “Methods to improve
compliance with screening, such as patient and health-care worker education,
financial support to attend visits and appropriate radiologic infrastructure
should be explored to reduce the impact of HCC in the co-infected population.”