Challenges and Controversies

There are no clear clinical guidelines on when to stop screening those with hepatitis B for HCC. Epidemiological studies have identified a number of factors that are associated with increased risk of developing HCC in those with chronic hepatitis B infection, including the presence of cirrhosis, male gender, higher levels of serum HBV DNA, genotype C infection, specific basal core promoter variations, and a family history of HCC. There have been several proposed scoring systems for HCC risk prediction incorporating these factors +/- co-morbidities, that can aid in the decision making process,each has had population limitations. Further investigation of these scoring systems is needed to validate the models in different patient populations.
In the meantime, the decision to stop HCC surveillance as in the case above needs to involve shared decision making and a discussion of the risks versus benefits of continuing or stopping that align with individual goals of care.

Although he has an undetectable HBV DNA and F2 fibrosis, he is still at increased risk for HCC thus should continue screening indefinitely. We are not told his ethnicity but people of Asian and African backgrounds are at increased risk for HCC also. People with chronic hep B who are treated and achieve an undetectable HBV DNA do have a decreased risk compared to no treatment; however, their risk for HCC is still above 0.2%, the threshold at which screening is cost-effective. In a study of nearly 1400 people who started entecavir, the annual incidence of HCC after 5 years of entecavir was 1.34%, which was lower than the 2.28% in the first 5 years of entecavir. In a meta-analysis including 12 studies with interferon treatment and 5 studies with nucleos(t)side treatment, risk reduction of HCC was 34% and 78%, respectively. Since people over 80 remain at increased risk for HCC if they have chronic hep B, screening should continue indefinitely unless the life expectancy is limited due to other conditions.