The edition · Gastroenterology & Hepatology
Liver cancer surveillance should be aimed at who benefits, not just who is at risk, and patient navigation beats every other way of raising screening uptake
An expert opinion argues abbreviated MRI and biomarker panels need benefit stratification rather than risk stratification, a network meta-analysis of 76 trials ranks colorectal screening interventions, and gene therapy cuts cornstarch dependence in glycogen storage disease type Ia.
The edition in brief
Six-monthly ultrasound and alpha-fetoprotein remain the recommended surveillance for hepatocellular carcinoma despite poor sensitivity for early tumours, poor adherence, and no randomised evidence of a mortality benefit in cirrhosis. A J Hepatology expert opinion assesses two replacements - abbreviated MRI protocols and blood biomarker panels such as GALAD, HES 2.0, Oncoguard and HelioLiver - and argues that who receives enhanced surveillance should be decided by expected benefit, not risk alone. The patients at highest risk of cancer are not necessarily those who gain most from finding it earlier. A companion review sets out why viral hepatitis elimination is stalling in low- and middle-income countries. The gaps are across the whole cascade - vaccination, prevention of mother-to-child transmission, screening, confirmatory testing, linkage, treatment initiation and follow-up - and the obstacles are structural rather than technological: centralised care models, weak laboratory infrastructure, cost, stigma and fragmented programmes. Decentralisation, point-of-care testing, self-testing and task sharing are the proposed answers. DTX401, an AAV8 gene therapy for glycogen storage disease type Ia, met its primary endpoint in a phase 3 double-blind randomised trial: daily cornstarch intake fell 41% against 10% on placebo at week 48 (p<0.0001), in 46 patients. Transaminase rises were managed with prophylactic corticosteroids. An EASL-AASLD Delphi panel of 62 clinicians, methodologists, regulators, industry and patients agreed 16 statements and 42 recommendations on endpoints for primary biliary cholangitis, where three second-line therapies hold conditional approval and full approval is blocked by unvalidated surrogate endpoints. Across 76 randomised trials, patient navigation (RR 1.58) and mailed faecal immunochemical test outreach (RR 1.36) raised colorectal screening uptake most; colonoscopy outreach did not beat usual care.
Who gains from liver cancer surveillance is a different question from who is at risk of liver cancer
Decide surveillance by expected benefit rather than cancer risk alone - a patient who would not be a candidate for curative treatment gains little from earlier detection.
Hepatitis elimination is stalling on systems, not on drugs
The bottleneck in viral hepatitis elimination is the care cascade rather than the drugs, so decentralised confirmatory testing, task sharing and integrated screening are the interventions that change outcomes.
Gene therapy cut cornstarch dependence by 41% in glycogen storage disease type Ia
AAV gene therapy reduced daily cornstarch intake by 41% against 10% on placebo in glycogen storage disease type Ia, close to the reduction patients said they wanted, but durability beyond 96 weeks is unknown.
EASL and AASLD set out what regulators would need to accept in primary biliary cholangitis
A joint EASL-AASLD Delphi consensus sets out the endpoint and real-world-evidence standards needed to move primary biliary cholangitis therapies from conditional to full approval; nothing changes in today's prescribing.
A negative faecal test in a symptomatic patient means nothing
A negative faecal immunochemical test does not exclude colorectal cancer in a symptomatic patient; alarm symptoms mean colonoscopy regardless of the result.
Patient navigation and posting the test out are what actually raise screening uptake
To raise colorectal cancer screening uptake, use patient navigation and mailed faecal test outreach - and in populations screening below 30%, mailed testing tripled uptake while colonoscopy invitations did no better than usual care.
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