New AASLD guideline focuses on improving diagnosis, treatment of liver cancer and NAFLD

A new Practice Guideline and Practice Guidance in Hepatology will help improve the diagnosis and treatment of patients with liver cancer as well as patients with non-alcoholic fatty liver disease (NAFLD), which can lead to liver cancer and is characterized by the build-up of extra fat in liver cells often due to obesity and diabetes.

Around the globe, there is an increasing burden of NAFLD and liver cancer, or hepatocellular carcinoma (HCC). A guidance document developed by a panel of experts to help clinicians understand and implement the most recent evidence related to NAFLD was commissioned by the American Association for the Study of Liver Diseases (AASLD). As an update to the Practice Guideline published in 2012 in conjunction with the American Gastroenterology Association and the American College of Gastroenterology, it provides more details about the value of lifestyle modification as a treatment of NAFLD and offers additional guidance concerning when to consider weight-loss surgery.

"Regarding diagnosis, this document provides guidance to clinicians with up-to-date information about working up individuals with suspected NAFLD, including when to consider liver biopsy. It also elaborates non-invasive tests for NAFLD," said lead author Naga Chalasani, MD, FAASLD, of the Indiana University School of Medicine. "Over the past 5 years since the 2012 Guideline, there have been important developments in our understanding related to noninvasive assessment with vibration controlled transient elastography and magnetic resonance elastography."

Experts present official recommendations of the AASLD on the surveillance, diagnosis, and treatment of HCC in an updated Practice Guideline. The guideline focuses on a broad spectrum of clinical practice, including surveillance of patients with cirrhosis (or liver scarring) for HCC, establishing the diagnosis of HCC, and various therapeutic options for the treatment of HCC. The current guideline was developed in compliance with the Institute of Medicine standards for trustworthy practice guidelines using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Multiple systematic reviews of the literature were conducted to support the recommendations in this practice guideline. An enhanced understanding of the guidelines can be obtained by reading the applicable portions of the systematic reviews.

"The updated HCC guideline is really focused on screening, diagnosis, and treatment of HCC. Our writing group worked to identify and address the most important clinical questions using what's called the Grading of Recommendation Assessment, Development and Evaluation (or GRADE) approach with systematic reviews to answer these key questions," said lead author Julie Heimbach, MD, of the Mayo Clinic, in Rochester, MN. "When compared with the previous guideline, notable changes include a surveillance guideline to recommend ultrasound plus alpha-fetoprotein—a standard tumor marker for HCC—instead of ultrasound alone, as well as the incorporation of recent studies for HCC informing the role of liver-directed therapies and newer systemic therapies—lenvatinib, regorafenib, and nivolumab."

The three new systematic reviews were performed to provide the evidence base to attempt to answer some of the key questions addressed in the new HCC guideline. One investigates the available evidence on the optimal imaging for the diagnosis of HCC. Another analyzes the published data on treatments for advanced stage HCC, while the final new systematic review focuses on the evidence supporting the use of bridging therapies for waitlisted liver transplant candidates with HCC.​