加拿大多伦多大学医学院Morris Sherman教授

   　肝癌风险评估的优势

 

　　肝癌风险评估评分的最大优点是可以明确哪些不需要进行肝癌筛查的患者。目前，肝病相关人群需要接受肝癌筛查的指导范围是非常广阔的。然而，多数患者实际上并不会发生肝癌。因此，我们面临的挑战是，如何确定这些不会患上癌症人群，这样就不必对他们进行定期检测筛查，也可以节省下不必要的花费和医疗资源，以及患者因此带来的不必要的焦虑。这就是风险评分的优势所在。

 

　　Dr. Sherman: The big advantage of a liver cancer risk assessment score is to identify patients who do not need to be screened. The guidelines for who should be screened at the moment are very, very broad. We know that many people who meet those guidelines will actually never develop cancer. So, the challenge is how you identify those patients who are never going to develop cancer so that you don’t have to subject them to regular screening with all of the attendant inconvenience and cost (and anxiety that this is going to provoke, unnecessarily). And so that’s what risk scores allows us to do-it allows us to identify patients who do not need to be screened.

 

　　不同病因的肝病患者肝癌的风险评估

 

　　在不同的人群中运用不同的肝癌风险评估模型。其中最重要的是根据患者特点，判断患者到底适合那种风险评估模型。例如，在亚洲慢性乙型肝炎患者中发展出了4~5个风险评估模型。如果你的患者是患有慢性乙型肝炎的亚洲人，那么你可以使用其中一个风险评估模型。如果你的患者是白种人，那么这些风险评估模型都不合适。同样，也有很多基于丙型肝炎的肝癌风险评估模型，然而只适合于具有丙型肝炎的人群。此外，这些评分是针对北美人群开发的，可能只适用于北美患者，是否可以用于其他地区仍不明确。

 

　　值得注意的是，有关肝硬化患者的肝癌风险评估，由于其病因的不同，例如慢性乙型肝炎、丙型肝炎、非酒精性脂肪肝、自身免疫性肝病等，所运用的肝癌风险评估模型也有所不同。有研究表明，不同原因的肝硬化患者，他们的肝癌风险存在着显著的差异。慢性乙型肝炎、丙型肝炎患者的肝癌风险较高，自身免疫性肝炎患者的肝癌风险较低。通过病因来也可以帮助我们判断患者需要进行肝癌筛查。

 

　　Dr. Sherman: So, different risk scores have been developed in different populations. The important thing is to look at the patient and say, well, which of these different populations does my patient fit into? So, for example, there are four or five risk scores for patients with Hepatitis B that were developed in Asia. If your patient is an Asian with Hepatitis B, you can use one of those. If your patient is a Caucasian with Hepatitis B, the risk score is not as good; they don’t work as well in the Caucasian population as they do in the Asian population, so you have to be a little careful with that. Then there are a bunch of risk scores for Hepatitis C, which should be applied, obviously, only to the Hepatitis C population. These were developed in North America, and presumably, applied to North America, and whether they are applied to other parts of the world is not clear. Then there are risk scores that have been developed for patients with cirrhosis, specifically, of any etiology, in which the risk scores where you actually enter the score, you plug the etiology.  So what this one study did was show that if you take a bunch of patients with cirrhosis with different etiologies-Hep B, Hep C, non-alcoholic fatty liver disease, and autoimmune liver disease-the incidents of cancer, and therefore the risk of cancer, is different even though they all have cirrhosis. The cause of the cirrhosis makes a difference into what your cancer risk is. So when you plug that into the score, then some patients with cirrhosis will get a higher score because they have Hepatitis B or Hepatitis C, and others will get a lower score because their cirrhosis was due to autoimmune hepatitis. And when you use that score, you can use the etiology to help you decide whether someone needs to be screened or not.

 

　　我们的研究主要是针对非酒精性脂肪肝相关的肝硬化患者，这些患者的肝癌风险较低，可能不需筛查，这方面的研究也尚未完全确定。目前，有两项来自台湾的研究表明，在慢性乙型肝炎和丙型肝炎患者中，转氨酶升高可显著增加患者的肝癌风险，另外性别和年龄也是重要的风险因素。中国的慢性乙型肝炎和丙型肝炎患者比例较高，推行肝癌风险评估应该有非常现实的意义。

 

　　Dr. Sherman: So, this particular study was done in non-alcoholic fatty liver disease patients with cirrhosis. There are no studies that look specifically at non-alcoholic fatty liver disease without cirrhosis. We do know that these patients get cancer at a low rate, and that the rate may be too low to warrant screening, but that has not yet been completely decided. There are two studies that I know of that look at the general population and the risk factors in the general population. These two studies, I think, are both from Taiwan. In one of them, actually, Hepatitis B and Hepatitis C come into the score (you get a certain number of points for Hepatitis B and Hepatitis C). One of them points out the importance of elevated transaminases-that if the transaminases are up, that increases your risk. The other one doesn’t look specifically at transaminases, but has things like gender and age, and it also includes Hepatitis B and Hepatitis C. So, those scores are perhaps useful in China where the risk for cancer in the general population is substantially high.

 

　　大会印象

 

　　在谈及对本届大会的印象时，他重点介绍了一项关于瑞戈非尼为期10年的临床研究获得了阳性结果，结果相当令人印象深刻。此外，在其他方面，也有一些肝癌治疗研究进展以及在遗传学和分子生物学方面的研究。Sherman教授强调说：肝癌领域近年来虽然没有取得巨大的进展，然而我们可以看到许多微小的进步。只有通过一点一点的积累，才能实现质的飞跃。

 

　　Dr. Sherman: Well, the highlight is actually not so much what’s at the meeting, but what’s happened just before the meeting, which is the regorafenib-positive study because it’s been ten years since we had the last positive study for liver cancer. So, that is a big deal. We heard Dr. Brusch do a presentation at the lunchtime meeting about this and the results were quite impressive. And so I think that’s a highlight even though it wasn’t stuff presented specifically at the meeting. For the rest, there are a number of smaller studies-treatment studies- a number of which may or may not eventually lead to licensed treatment strategies. And then there were a number of studies looking at genetics and the molecular biology, which I think move us a little bit forward. It is by no means a big leap, but these are never going to be big leaps. It’s always going to be small little steps. So, I think there were a couple more small steps that were presented at this meeting.