Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, United States; Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, United States; Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States.
Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States.
J Hepatol. 2019 Sep;71(3):523-533. doi: 10.1016/j.jhep.2019.05.008. Epub 2019 May 28.
BACKGROUND & AIMS: Hepatocellular carcinoma (HCC) risk varies dramatically in patients with cirrhosis according to well-described, readily available predictors. We aimed to develop simple models estimating HCC risk in patients with alcohol-related liver disease (ALD)-cirrhosis or non-alcoholic fatty liver disease (NAFLD)-cirrhosis and calculate the net benefit that would be derived by implementing HCC surveillance strategies based on HCC risk as predicted by our models.
We identified 7,068 patients with NAFLD-cirrhosis and 16,175 with ALD-cirrhosis who received care in the Veterans Affairs (VA) healthcare system in 2012. We retrospectively followed them for the development of incident HCC until January 2018. We used Cox proportional hazards regression to develop and internally validate models predicting HCC risk using baseline characteristics at entry into the cohort in 2012. We plotted decision curves of net benefit against HCC screening thresholds.
We identified 1,278 incident cases of HCC during a mean follow-up period of 3.7 years. Mean annualized HCC incidence was 1.56% in NAFLD-cirrhosis and 1.44% in ALD-cirrhosis. The final models estimating HCC were developed separately for NAFLD-cirrhosis and ALD-cirrhosis and included 7 predictors: age, gender, diabetes, body mass index, platelet count, serum albumin and aspartate aminotransferase to √alanine aminotransferase ratio. The models exhibited very good measures of discrimination and calibration and an area under the receiver operating characteristic curve of 0.75 for NAFLD-cirrhosis and 0.76 for ALD-cirrhosis. Decision curves showed higher standardized net benefit of risk-based screening using our prediction models compared to the screen-all approach.
We developed simple models estimating HCC risk in patients with NAFLD-cirrhosis or ALD-cirrhosis, which are available as web-based tools (www.hccrisk.com). Risk stratification can be used to inform risk-based HCC surveillance strategies in individual patients or healthcare systems or to identify high-risk patients for clinical trials.
Patients with cirrhosis of the liver are at risk of getting hepatocellular carcinoma (HCC or liver cancer) and therefore it is recommended that they undergo surveillance for HCC. However, the risk of HCC varies dramatically in patients with cirrhosis, which has implications on if and how patients get surveillance, how providers counsel patients about the need for surveillance, and how healthcare systems approach and prioritize surveillance. We used readily available predictors to develop models estimating HCC risk in patients with cirrhosis, which are available as web-based tools at www.hccrisk.com.
根据易于描述和获取的预测因子，肝癌（HCC）风险在肝硬化患者中差异巨大。我们旨在开发能够估算酒精性肝病（ALD）-肝硬化或非酒精性脂肪性肝病（NAFLD）-肝硬化患者 HCC 风险的简单模型，并计算通过我们的模型预测 HCC 风险而实施 HCC 监测策略所带来的净获益。
我们在 2012 年从退伍军人事务部（VA）医疗保健系统中确定了 7068 例 NAFLD-肝硬化患者和 16175 例 ALD-肝硬化患者，并对他们进行了随访，以观察 HCC 的发病情况，直至 2018 年 1 月。我们使用 Cox 比例风险回归来开发和内部验证预测 HCC 风险的模型，使用 2012 年进入队列时的基线特征。我们绘制了净获益与 HCC 筛查阈值的决策曲线。
在平均 3.7 年的随访期间，我们发现了 1278 例 HCC 发病病例。NAFLD-肝硬化患者的 HCC 年发生率为 1.56%，ALD-肝硬化患者的 HCC 年发生率为 1.44%。用于估算 HCC 的最终模型分别为 NAFLD-肝硬化和 ALD-肝硬化开发，包括 7 个预测因子：年龄、性别、糖尿病、体重指数、血小板计数、血清白蛋白和天冬氨酸转氨酶与丙氨酸转氨酶比值的平方根。这些模型的区分度和校准度均表现出色，NAFLD-肝硬化和 ALD-肝硬化的受试者工作特征曲线下面积分别为 0.75 和 0.76。决策曲线显示，与筛查所有患者的方法相比，使用我们的预测模型进行基于风险的筛查具有更高的标准化净获益。
我们开发了用于估算 NAFLD-肝硬化或 ALD-肝硬化患者 HCC 风险的简单模型，这些模型可作为基于网络的工具使用（www.hccrisk.com）。风险分层可用于为个体患者或医疗保健系统提供基于风险的 HCC 监测策略的信息，或用于识别临床试验中的高危患者。
肝硬化患者有发生肝细胞癌（HCC 或肝癌）的风险，因此建议对其进行 HCC 监测。然而，肝硬化患者的 HCC 风险差异巨大，这对患者是否以及如何接受监测、提供者如何向患者告知监测的必要性以及医疗保健系统如何处理和优先考虑监测具有影响。我们使用易于获取的预测因子来开发估算肝硬化患者 HCC 风险的模型，这些模型可作为基于网络的工具使用，网址为 www.hccrisk.com。
