Impact of Hepatocellular Cancer: Worldwide, hepatocellular carcinoma (HCC) is the sixth most common malignancy (Figure 1) and the third most common cause of cancer-related death (Figure 2). In the United States, HCC is the fastest growing cause of cancer-related death. The incidence of HCC in the United States has increased in recent years (Figure 3), largely attributable to a significant rise in hepatitis C-related HCC. In the United States, it is estimated that in 2013 there will be 30,640 new cases diagnosed and 21,670 deaths due to hepatitis C-related HCC.
Risk Factors: Cirrhosis from any cause is the primary risk factor for HCC: approximately 80% of cases of HCC occur in individuals with cirrhosis and the risk of developing HCC increases with fibrosis stage. Chronic HCV and chronic hepatitis B virus (HBV) infection are the most common risk factors for HCC. In the United States, approximately 50 to 60% of persons with HCC are infected with hepatitis C. Patients with chronic hepatitis C and cirrhosis have a 2 to 5% annual risk and a 7% to 14% risk over 5 years of developing HCC. The risk of developing HCC among persons infected with HCV increases with substantial alcohol intake—the risk increases in a linear fashion with daily alcohol intake greater than 60 g (approximately 6 cans of beer, shots of liquor, or glasses of wine). The overall incidence rate of HCC is approximately three times higher in males than females (Figure 4). Any patient with cirrhosis can develop HCC, including patients with cirrhosis from non-viral causes, such as alcoholic cirrhosis, autoimmune hepatitis, non-alcoholic fatty liver disease, hemochromatosis, glycogen storage disease, Wilson’s disease, alpha-1-antitrypsin deficiency, and porphyria cutanea tarda.
Prognosis: The overall prognosis for patients diagnosed with HCC in the United States is poor, with an estimated median survival of 4.3 to 20 months and a 5-year survival of 10 to 15%. In general, patients who have HCC detected after the onset of symptoms have an extremely poor prognosis, with an overall 5-year survival of 0 to 10%. Symptoms may include abdominal pain, anorexia, early satiety, weight loss, obstructive jaundice, fever, watery diarrhea, and bone pain (from metastases). A select group of patients with good performance status who have HCC diagnosed at an early stage have a predicted survival longer than 5 years, but unfortunately most patients with HCC have advanced stages of cancer at the time of diagnosis.
Rationale for HCC Surveillance: The rationale for conducting HCC surveillance is that regular screening of at-risk asymptomatic patients may detect tumors at an early stage when potentially curative treatment can be offered.