Oliver Waidmann, MD: For patients with HCC, early diagnosis is really, really important, because if they have a tumor in an early stage, you can really do a curative treatment for these patients—namely resection, ablation, or liver transplantation. All patients should get screening, and the most important is that patients with liver fibrosis, and even advanced cirrhosis, get regular treatment. So, we have a big problem. We have increasing rates of nonalcoholic steatohepatitis and nonalcoholic fatty liver disease. And, of course, we will get more and more patients. In the Western world, 30% of patients have fatty liver disease, and, of course, we cannot do screening in all patients. But we have to do some kind of risk adaption for these patients. That means if you have a patient with fatty liver disease, you should do some kind of noninvasive fibrosis determination. And in these patients, if they have fibrosis or established cirrhosis, you should do the screening. In patients where they don’t really have fibrosis, we don’t have to do the screening parameters. So, if we need AFP or not, it’s a big, good question. I think there are not good data for AFP, so the most important for me is doing screening with ultrasound.

Arndt Vogel, MD: In the past few years, the underlying liver diseases leading to hepatocellular carcinomas have changed. In the past, many patients, and still most patients, have viral hepatitis. Viral hepatitis could be either hepatitis B or hepatitis C. For hepatitis C, we now do have very effective antiviral treatments, and until diagnosis of hepatitis C is made, the patients can be cured. So, the greatest challenge will be to identify those patients who have hepatitis C because hepatitis C by itself does not make any problems unless the patient has really advanced liver fibrosis or cirrhosis. Identifying those patients is important, then we can clearly eradicate this disease. For hepatitis B, we do not yet have a cure available, but we have very effective treatments. In recent years, it became very evident that with a good antiviral treatment, we can reduce the liver inflammation, and with that, we can also reduce incidence of hepatocellular carcinoma. Together, this indicates viral hepatitis as, at the moment, clearly a concern, and it will also contribute in the next 5 to 10 years to the occurrence of hepatocellular carcinoma. But this will change then because we have good treatment options for both.

On the other hand, we have other diseases, such as specifically fatty liver disease, which will very likely contribute to at least a maintenance of the incidence of HCC because we have still an increasing problem of obesity, and obesity is a very strong risk factor for the development of hepatocellular carcinoma. So, I think we will have a shift from viral hepatitis more to metabolic diseases such as fatty liver, NAFLD, and NASH.

Since we have the change in risk population, screening will be critically important. In the past, it was somehow easy because specifically patients with viral hepatitis were those that were at risk to develop HCC. And with most patients who are diagnosed with hepatitis C, we could transfer them to screening programs. In most countries, we would recommend screening based on ultrasound, and I think also it should include tumor markers such as AFP. On the other hand, now we have the problem that we have more and more patients with obesity and patients with obesity are at risk to develop HCC. And those patients might also develop HCC in a noncirrhotic liver. So, if we now think about all these people with obesity and fatty liver disease, we have a lot of people we would need to screen. And additionally, in patients with fatty liver disease, screening by ultrasound is extremely difficult because due to the fatty liver, it’s even more difficult to identify tumor nodules. It’s really, clearly, a challenge in the future. We do know that patients with chronic liver disease develop HCC, so the population at risk is clearly defined, and we have the problem that we have this shift in underlying liver diseases with a lot of people with fatty liver. We have a lot of patients or potential candidates for HCC, which will make the screening very, very difficult.

Transcript Edited for Clarity

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