Models estimating risk of hepatocellular carcinoma in patients with alcohol or NAFLD-related cirrhosis for risk stratification

• Published in: Journal of hepatology 2019-09, Vol.71 (3), p.523-533
• Main Authors: Ioannou, George N., Green, Pamela, Kerr, Kathleen F., Berry, Kristin
• Format: Article
• Language: English
• Subjects: Aged; Alanine; Alanine transaminase; Alcohol; Aspartate aminotransferase; Body mass index; Carcinoma, Hepatocellular - epidemiology; Carcinoma, Hepatocellular - etiology; Cirrhosis; Clinical trials; Diabetes mellitus; Fatty liver; Female; Follow-Up Studies; HCC; Hepatocellular carcinoma; Humans; Incidence; Liver cancer; Liver cirrhosis; Liver Cirrhosis, Alcoholic - complications; Liver diseases; Liver Neoplasms - epidemiology; Liver Neoplasms - etiology; Male; Middle Aged; Models, Statistical; NAFLD; Non-alcoholic fatty liver disease; Non-alcoholic Fatty Liver Disease - complications; Prediction models; Proportional Hazards Models; Regression analysis; Retrospective Studies; Risk Assessment; Risk Factors; Risk groups; Risk model; Surveillance; United States - epidemiology; Veterans
• ISSN: 0168-8278; 1600-0641; 1600-0641
• DOI: 10.1016/j.jhep.2019.05.008

[Display omitted] •HCC risk varies dramatically in patients with cirrhosis.•We developed models estimating HCC risk in patients with NAFLD-cirrhosis or ALD-cirrhosis.•The models use simple, readily available predictors.•The models are available as web-based tools at www.hccrisk.com. 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 survei