Liver and Bile
J Hepatol. 2022;76(2):294–301
Comparative performance of risk prediction models for hepatitis B-related hepatocellular carcinoma in the United States
Background and aims: Guidelines recommend hepatocellular carcinoma (HCC) surveillance in patients with chronic hepatitis B virus (HBV) infection. Several HCC risk prediction models are available to guide surveillance decisions, but their comparative performance remains unclear.
Methods: Using a retrospective cohort of patients with HBV treated with nucleos(t)ide analogues at 130 Veterans Administration facilities between September 1, 2008, and December 31, 2018, the authors calculated risk scores from 10 HCC risk prediction models (REACH-B, PAGE-B, m-PAGE-B, CU-HCC, HCC-RESCUE, CAMD, APA-B, REAL-B, AASL-HCC, RWS-HCC). They estimated the models’ discrimination and calibration, and calculated HCC incidence in risk categories defined by the reported cut-offs for all models.
Results: Of 3101 patients with HBV (32.2% with cirrhosis), 47.0% were treated with entecavir, 40.6% with tenofovir, and 12.4% received both. During a median follow-up of 4.5 years, 113 patients developed HCC at an incidence of 0.75/100 person-years. Area under the curve (AUC) values for 3-year HCC risk were the highest for RWS-HCC, APA-B, REAL-B, and AASL-HCC (all > 0.80). Of these, 3 (APA-B, RWS-HCC, REAL-B) incorporated alpha-fetoprotein. AUC values for the other models ranged from 0.73 for PAGE-B to 0.79 for CAMD and HCC-RESCUE. Of the 7 models with AUC > 0.75, only APA-B was poorly calibrated. In total, 10–20% of the cohort was deemed low-risk based on the published cut-offs. None of the patients in the low-risk groups defined by PAGE-B, m-PAGE-B, AASL-HCC, and REAL-B developed HCC during the study timeframe.
Conclusion: In this national cohort of US-based patients with hepatitis B virus infection on antiviral treatment, most models performed well in predicting hepatocellular carcinoma (HCC) risk. A low-risk group, in which no cases of HCC occurred within a 3-year timeframe, was identified by several models (PAGE-B, m-PAGE-B, CAMD, AASL-HCC, REAL-B). Further studies are warranted to examine whether these patients could be excluded from HCC surveillance.