Should we screen for cirrhosis?
Recent guidelines are right to recommend screening high risk patients for cirrhosis, say liver specialists Mark Hudson at Freeman Hospital, Newcastle upon Tyne, and Nick Sheron at Southampton General Hospital.
They say liver disease will probably overtake heart disease to become the commonest cause of death in working age people in the next year or so, mainly because it develops without signs or symptoms and options to tackle alcohol and obesity - the commonest causes of liver disease - are limited.
Yet technologies to identify early liver disease exist, they say, and are supported by the National Institute for Health and Care Excellence (NICE).
NICE recommends that men and women drinking alcohol at potentially harmful levels - more than 50 and 35 units a week, respectively - be offered a test (transient elastography) to exclude cirrhosis. This equates to about 2.25 million people in England and Wales.
They point out that few GPs currently have access to this test, "so it is not going to happen overnight." However, because the lifetime cost of treating liver disease is between £50,000 and £120,000, "this approach is likely to be cost effective," they write.
"We will need properly controlled trials, and these studies are in preparation," they say. "However, the burden of liver disease is such that doctors cannot simply sit in their ivory towers waiting for patients with liver disease to come and find them."
But other experts argue that despite recent recommendations from NICE, "insufficient evidence supports a screening programme for cirrhosis."
Liver specialists Ian Rowe at the University of Leeds, and Gideon Hirschfield at Birmingham University's Liver Research Centre, say "for a successful screening programme the test used must be simple, cheap, and, most importantly, accurate."
Yet the test proposed to screen for cirrhosis has been shown to perform poorly in people suspected to have alcohol related liver disease, leading to many healthy people being incorrectly labelled as having cirrhosis and subject to further medical intervention, which comes with risk of physical and mental harm.
Also, the test "is not widely available and would require huge up-front investment to establish it in community settings," and "is probably not cost effective," they warn.
As such, they believe that implementation of screening for cirrhosis "would inevitably lead to disinvestment in other, more effective interventions, risking the overall health of the population."
Instead, they say resources should be targeted at managing risk factors for common liver diseases, such as alcohol consumption and obesity, as well as investing in well designed trials that evaluate the clinical and cost effectiveness of screening strategies.