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Yilmaz et al. Hepatoma Res 2018;4:46 I http://dx.doi.org/10.20517/2394-5079.2018.49 Page 7 of 10

studied in screening set-up [2,26,30] .

As imaging modality, Japanese guidelines recommend EOB-MRI or dynamic CT to be performed in every
6-12 months for screening for extremely high-risk of cirrhotic patients since small nodules may not be de-
tected on ultrasound alone [32,34] .

HCC risk stratification models for cirrhotics have not yet been included in the guidelines and the majority of
the presented guidelines exclude Child C cirrhosis from screening protocols unless they are eligible for cura-
tive therapy.

Screening guidelines for non-cirhotics differ from countries, mainly in selection of the target population.
Whereas AASLD-2017 does not specify, APASL-2017 and EASL-2018 describe the target population in the
guidelines.

EASL-2018 made a breakthrough and used the PAGE B score system for non-cirrhotic HBV patients. The
score system is intended to determine unnecessary screening for Caucasian patients with chronic HBV.
[2]
However, the PAGE-B score has not yet been validated in Asia .
Overall F3 (bridging fibrosis) patients regardless of aetiology were also included in the screening protocol at
first time by EASL-2018 developers.

CHINESE-2017 recommends screening for patients with chronic liver diseases regardless of aetiology. In
contrast, Japan guidelines suggest screening for patients with only chronic HBV and HCV.

In general, the screening modalities for non-cirhotics are almost identical with cirrhotics except Japan
guidelines. The Japan guidelines recommend the three tumour markers additional to ultra-sonogram, for
every 6 months.

Final question is: do the screening modalities really work? Japan and Hong Kong HCC screening methods
were compared in that particular context. In Hong Kong, where there was no formal surveillance program,
20% of HCC were detected only in the pre-symptomatic period with low survival rate (17.8 months) whereas
in Japan over 75% of cases were detected by surveillance. The median survival was 52 months in Japan and
the stage of HCC at presentation was the most important factor influencing survival according to the co-
[47]
hort .

CONCLUSION
Recommendations from the three continents are mostly influenced in the prevalence of HCC and availabil-
ity of resources. It may be necessary to modify the screening methods according to the condition of patients.
This situation is more evident in those countries with no national guidelines and/or heterogeneous patient
population. Hence, developing countries should be encouraged to issue their own guidelines. The common
point is that, cost-effectiveness is universal and screening modality is one of the factors that influence the
variation in survival.

DECLARATIONS
Acknowledgments
Special thanks to Burhan Gurtunca, PhD for his contributions on editing.