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Preventing hepatocellular carcinoma: the crucial role of chronic hepatitis B monitoring and antiviral treatment.

Liver cancer is the second leading cause of cancer death worldwide, responsible for an estimated 746,000 deaths and 782,000 new cases in 2012 [1]. The countries in the Western Pacific region accounts for 64% and China alone accounts for 51% of the new liver cancer cases and deaths each year. Approximately 80% of hepatocellular carcinoma (HCC), the most common type of liver cancer, is associated with viral hepatitis [1]. In countries with high prevalence of hepatitis B virus (HBV) infection, such as China, up to 80% of HCC is associated with hepatitis B [2]. Liver cancer carries a poor prognosis with a global mortality to incidence ratio of 0.95 [1]. In the USA, the 1-year survival rate remains less than 50% [3]. Asians and Pacific Islanders have the highest incidence of HCC among the different racial/ethnic groups. While every individual with chronic hepatitis B infection (CHB) or HBV carrier is at risk for developing HCC, disease progression leading to cirrhosis is associated with the greatest risk [2]. In an effort to improve survival through early detection of HCC, the American Association for the Study of Liver Diseases recommended HCC screening with abdominal ultrasound (US) at 6–12 month intervals of HBV carriers considered at increased risk for HCC, including those with cirrhosis, family history of liver cancer and Asian male HBV carriers above the age of 40 [4,5]. However, it remains controversial whether population-wide HCC screening of CHB patients results in a reduction in HCC mortality particularly in resource-constraint regions of the world that have the highest burden of HCC. The only two randomized trials available to date are both from China [6,7]. A population-based study in the city of Shanghai, conducted by the Liver Cancer Institute of Fudan University, reported 1-year HCC survival rates improved from 31.2% in the control group to 65.9% in the screened group among 18,816 CHB patients aged 35–59 years with or without cirrhosis, who were randomized into either a group using US and AFP screening every 6 months or a control group [6]. The second study from a rural setting in Qidong, using AFP screening every 6 months without US, did not show any improvement in survival [7]. According to the National Cancer Institute [8], screening for HCC