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Goldberg D, Wilder J, Terrault N. Health disparities in cirrhosis care and liver transplantation. Nat Rev Gastroenterol Hepatol 2025; 22:98-111. [PMID: 39482363 DOI: 10.1038/s41575-024-01003-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2024] [Indexed: 11/03/2024]
Abstract
Morbidity and mortality from cirrhosis are substantial and increasing. Health disparities in cirrhosis and liver transplantation are reflective of inequities along the entire spectrum of chronic liver disease care, from screening and diagnosis to prevention and treatment of liver-related complications. The key populations experiencing disparities in health status and healthcare delivery include racial and ethnic minority groups, sexual and gender minorities, people of lower socioeconomic status and underserved rural communities. These disparities lead to delayed diagnosis of chronic liver disease and complications of cirrhosis (for example, hepatocellular carcinoma), to differences in treatment of chronic liver disease and its complications, and ultimately to unequal access to transplantation for those with end-stage liver disease. Calling out these disparities is only the first step towards implementing solutions that can improve health equity and clinical outcomes for everyone. Multi-level interventions along the care continuum for chronic liver disease are needed to mitigate these disparities and provide equitable access to care.
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Affiliation(s)
- David Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami, Miami, FL, USA
| | - Julius Wilder
- Division of Gastroenterology, Duke University, Durham, NC, USA
| | - Norah Terrault
- Division of GI and Liver Diseases, University of Southern California, Los Angeles, CA, USA.
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2
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Moussa D, Flores JE, Doyle JS, Ryan M, Wallace J, Howell J. Synthesising enablers and barriers to hepatocellular carcinoma surveillance-A systematic review of qualitative findings. PLoS One 2025; 20:e0313216. [PMID: 39792827 PMCID: PMC11723554 DOI: 10.1371/journal.pone.0313216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 10/21/2024] [Indexed: 01/12/2025] Open
Abstract
BACKGROUND & AIMS This systematic literature review of qualitative findings aims to identify the perceived barriers and enablers for hepatocellular carcinoma (HCC) surveillance from patient and clinician perspectives. METHODS A systematic search of databases using key term combinations with the following inclusion criteria: 1) qualitative and quantitative (survey) studies exploring barriers and enablers of HCC surveillance, and 2) qualitative and quantitative (survey) studies exploring barriers and enablers of enagagement in clinical care for patients with cirrhosis and/or viral hepatitis. RESULTS The search returned 445 citations: 371 did not meet the study criteria and were excluded. 74 studies proceeded to full-text review, leading to 21 included studies (15 studies from searching with a further six studies from citation review) progressing to data extraction by two independent reviewers. Results from studies exploring patients' perspectives reinforce that barriers are experienced by patients across different health settings, cultures, and regions. Logistical barriers including costs and transportation, and knowledge/awareness barriers were commonly identified. Studies that included clinician perspectives highlighted the need for healthcare provider education and system-level interventions to optimize HCC surveillance uptake in clinical practice. CONCLUSION These findings highlight the critical need for interventions that enable engagement in HCC surveillance in health services.
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Affiliation(s)
- Dina Moussa
- University of Melbourne, Australia
- St Vincent’s Hospital Melbourne, Australia
- Disease Elimination Program, Burnet Institute, Australia
| | - Joan Ericka Flores
- University of Melbourne, Australia
- St Vincent’s Hospital Melbourne, Australia
| | - Joseph S. Doyle
- Disease Elimination Program, Burnet Institute, Australia
- Department of Infectious Diseases, Alfred Health and Monash University, Australia
| | - Marno Ryan
- St Vincent’s Hospital Melbourne, Australia
| | - Jack Wallace
- Disease Elimination Program, Burnet Institute, Australia
- Australian Research Centre in Sex, Health and Society, Latrobe University, Australia
- Centre for Social Research in Health, UNSW Sydney, Australia
| | - Jessica Howell
- University of Melbourne, Australia
- St Vincent’s Hospital Melbourne, Australia
- Disease Elimination Program, Burnet Institute, Australia
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3
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Kazi IA, Jahagirdar V, Kabir BW, Syed AK, Kabir AW, Perisetti A. Role of Imaging in Screening for Hepatocellular Carcinoma. Cancers (Basel) 2024; 16:3400. [PMID: 39410020 PMCID: PMC11476228 DOI: 10.3390/cancers16193400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2024] [Revised: 09/22/2024] [Accepted: 09/26/2024] [Indexed: 10/20/2024] Open
Abstract
Primary liver cancer is among the most common cancers globally. It is the sixth-most common malignancy encountered and the third-most common cause of cancer-related death. Hepatocellular carcinoma (HCC) is the most common primary liver malignancy, accounting for about 90% of primary liver cancers. The majority of HCCs occur in patients with underlying cirrhosis, which results from chronic liver diseases such as fatty liver, hepatitis B and hepatitis C infections, and chronic alcohol use, which are the leading causes. The obesity pandemic has led to an increased prevalence of nonalcoholic fatty liver disease (NAFLD), which leads to nonalcoholic steatohepatitis and could progress to cirrhosis. As HCC is among the most common cancers and occurs in the setting of chronic liver disease in most patients, screening the population at risk could help in early diagnosis and management, leading to improved survival. Screening for HCC is performed using biochemical marker testing such as α-fetoprotein (AFP) and cross-sectional imaging. It is critical to emphasize that HCC could potentially occur in patients without cirrhosis (non-cirrhotic HCC), which can account for almost 20% of all HCCs. The lack of cirrhosis can cause a delay in surveillance, which could potentially lead to diagnosis at a later stage, worsening the prognosis for such patients. In this article, we discuss the diagnosis of cirrhosis in at-risk populations with details on the different modalities available for screening HCC in patients with cirrhosis, emphasizing the role of abdominal ultrasounds, the primary imaging modality in HCC screening.
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Affiliation(s)
- Irfan A. Kazi
- Department of Radiology, University of Missouri Columbia, Columbia, MO 65212, USA;
| | - Vinay Jahagirdar
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA 23298, USA;
| | - Bareen W. Kabir
- Department of Internal Medicine, University of Missouri Columbia, Columbia, MO 65212, USA;
| | - Almaan K. Syed
- Blue Valley Southwest High School, Overland Park, KS 6622, USA;
| | | | - Abhilash Perisetti
- Division of Gastroenterology and Hepatology, Kansas City Veteran Affairs, Kansas City, MO 64128, USA
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4
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Moon AM, Swier RM, Lane LM, Barritt AS, Sanoff HK, Olshan AF, Wheeler SB, Ioannou GN, Kim NJ, Hagan S, Vutien P, Benefield T, Henderson LM. Statewide Survey of Primary Care and Subspecialty Providers on Hepatocellular Carcinoma Risk-Stratification and Surveillance Practices. Dig Dis Sci 2024; 69:2437-2449. [PMID: 38652392 DOI: 10.1007/s10620-024-08442-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis is associated with improved survival. Provision of HCC surveillance is low in the US, particularly in primary care settings. AIMS To evaluate current hepatitis C virus (HCV) and HCC surveillance practices and physician attitudes regarding HCC risk-stratification among primary care and subspecialty providers. METHODS Using the Tailored Design Method, we delivered a 34-item online survey to 7654 North Carolina-licensed internal/family medicine or gastroenterology/hepatology physicians and advanced practice providers in 2022. We included the domains of HCV treatment, cirrhosis diagnosis, HCC surveillance practices, barriers to surveillance, and interest in risk-stratification tools. We performed descriptive analyses to summarize responses. Tabulations were weighted based on sampling weights accounting for non-response and inter-specialty comparisons were made using chi-squared or t test statistics. RESULTS After exclusions, 266 responses were included in the final sample (response rate 3.8%). Most respondents (78%) diagnosed cirrhosis using imaging and a minority used non-invasive tests that were blood-based (~ 15%) or transient elastography (31%). Compared to primary care providers, subspecialists were more likely to perform HCC surveillance every 6-months (vs annual) (98% vs 35%, p < 0.0001). Most respondents (80%) believed there were strong data to support HCC surveillance, but primary care providers did not know which liver disease patients needed surveillance. Most providers (> 70%) expressed interest in potential solutions to improve HCC risk-stratification. CONCLUSIONS In this statewide survey, there were great knowledge gaps in HCC surveillance among PCPs and most respondents expressed interest in strategies to increase appropriate HCC surveillance.
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Affiliation(s)
- Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- UNC Liver Center, University of North Carolina at Chapel Hill School of Medicine, 8009 Burnett Womack Bldg, CB#7584, Chapel Hill, NC, 27599-7584, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
| | - Rachel M Swier
- Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lindsay M Lane
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - A Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Liver Center, University of North Carolina at Chapel Hill School of Medicine, 8009 Burnett Womack Bldg, CB#7584, Chapel Hill, NC, 27599-7584, USA
| | - Hanna K Sanoff
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Andrew F Olshan
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicole J Kim
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Scott Hagan
- Division of General Internal Medicine, University of Washington, VA Puget Sound Healthcare System, Seattle, USA
| | - Philip Vutien
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Thad Benefield
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Louise M Henderson
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
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Igissin N, Orazbayev D, Telmanova Z, Kudaibergenova I, Mamatov N, Bilyalova Z, Igissinova G, Rustemova K, Turebayev D, Jexenova A, Adaibayev K, Sayakov U, Dzhumabayeva F, Muratbekova S, Sitnikova L, Syzdykov N, Shishkin I, Kozhakhmet K. Liver Cancer Incidence in Kazakhstan: Fifteen-Year Retrospective Study. Asian Pac J Cancer Prev 2024; 25:1763-1775. [PMID: 38809649 PMCID: PMC11318810 DOI: 10.31557/apjcp.2024.25.5.1763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/04/2024] [Indexed: 05/31/2024] Open
Abstract
OBJECTIVE The aim is to study the trends of liver cancer (LC) incidence in the regional context in Kazakhstan. METHODS The retrospective study was done using descriptive and analytical methods of oncoepidemiology. The extensive, crude and age-specific incidence rates are determined according to the generally accepted methodology used in sanitary statistics. The data were used to calculate the average percentage change (APС) using the Joinpoint regression analysis to determine the trend over the study period. RESULTS Between 2005 and 2019, 13,510 cases of LC were documented, comprising 59.3% males and 40.7% females. Most diagnoses were seen in age groups 55-59 years (13.3%) to 75-79 years (11.7%). LC patients' average age increased from 63.6 to 64.5 years. Incidence rates per 100,000 peaked at ages 65-69 years (35.1±1.0) and 70-74 years (43.3±1.0). LC incidence notably rose in the 70-74 years age group (APC=+0.89), contrasting with declining trends in younger age groups. Regional incidence variations revealed diverse patterns, mostly demonstrating unimodal increases, and some regions displaying bimodal growth. The age-standardized incidence rate was 5.7±0.1 per 100,000, declining from 2005 to 2012 (APC: -3.93), then rising until 2019 (APC: +1.13). Gender-specific standardized rates showed varied trends. Analyses of standardized indicators indicated declining trends in most regions but increased values in specific areas. Thematic maps classified incidence rates based on standardized indicators: low (up to 5.22), average (5.22 to 7.11), high (above 7.11 per 100,000 for the entire population). CONCLUSION The study on liver cancer in Kazakhstan reveals marked gender and age differences. The standardized incidence rate among men was twofold greater than that among women. A distinct rise in cases was noted among individuals aged 70-74 years. Regional variations in incidence were evident. These findings emphasize the necessity for focused research to comprehend the causes behind these differences, enabling customized interventions for Kazakhstan's population.
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Affiliation(s)
- Nurbek Igissin
- Research Institute of Life and Health Sciences, Higher School of Medicine, Kokshetau University named after Sh. Ualikhanov, Kokshetau, Kazakhstan.
- Central Asian Institute for Medical Research, Astana, Kazakhstan
- Asian Pacific Organization for Cancer Prevention, Bishkek, Kyrgyzstan.
| | - Didar Orazbayev
- Central Asian Institute for Medical Research, Astana, Kazakhstan
- Astana Medical University, Astana, Kazakhstan.
- Akhunbaev Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan.
| | | | - Indira Kudaibergenova
- Asian Pacific Organization for Cancer Prevention, Bishkek, Kyrgyzstan.
- Akhunbaev Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan.
| | - Niyazbek Mamatov
- Asian Pacific Organization for Cancer Prevention, Bishkek, Kyrgyzstan.
- Akhunbaev Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan.
| | - Zarina Bilyalova
- Central Asian Institute for Medical Research, Astana, Kazakhstan
- Asian Pacific Organization for Cancer Prevention, Bishkek, Kyrgyzstan.
| | - Gulnur Igissinova
- Central Asian Institute for Medical Research, Astana, Kazakhstan
- Asfendiyarov Kazakh National Medical University, Almaty, Kazakhstan.
| | - Kulsara Rustemova
- Central Asian Institute for Medical Research, Astana, Kazakhstan
- Astana Medical University, Astana, Kazakhstan.
| | - Dulat Turebayev
- Akhunbaev Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan.
| | | | - Kairat Adaibayev
- Central Asian Institute for Medical Research, Astana, Kazakhstan
- Astana Medical University, Astana, Kazakhstan.
| | - Umetaly Sayakov
- Akhunbaev Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan.
| | | | - Svetlana Muratbekova
- Higher School of Medicine, Kokshetau University named after Sh. Ualikhanov, Kokshetau, Kazakhstan.
| | | | - Nariman Syzdykov
- Central Asian Institute for Medical Research, Astana, Kazakhstan
- Akhunbaev Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan.
- Academy of Public Administration under the President of the Republic of Kazakhstan”, Astana, Kazakhstan.
| | - Ivan Shishkin
- Central Asian Institute for Medical Research, Astana, Kazakhstan
- Higher School of Medicine, Kokshetau University named after Sh. Ualikhanov, Kokshetau, Kazakhstan.
| | - Karina Kozhakhmet
- Central Asian Institute for Medical Research, Astana, Kazakhstan
- Higher School of Medicine, Kokshetau University named after Sh. Ualikhanov, Kokshetau, Kazakhstan.
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6
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Wong RJ, Jones PD, Niu B, Therapondos G, Thamer M, Kshirsagar O, Zhang Y, Pinheiro P, Kyalwazi B, Fass R, Khalili M, Singal AG. Clinician-Level Knowledge and Barriers to Hepatocellular Carcinoma Surveillance. JAMA Netw Open 2024; 7:e2411076. [PMID: 38743424 PMCID: PMC11094557 DOI: 10.1001/jamanetworkopen.2024.11076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/12/2024] [Indexed: 05/16/2024] Open
Abstract
Importance Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is underused. Identifying potentially modifiable factors to address barriers in HCC surveillance is critical to improve patient outcomes. Objective To evaluate clinician-level factors contributing to underuse of HCC surveillance in patients with cirrhosis. Design, Setting, and Participants This survey study included primary care clinicians (PCCs) and gastroenterology and hepatology clinicians at 5 safety-net health systems in the US. Clinicians were surveyed from March 15 to September 15, 2023, to assess knowledge, attitudes, beliefs, perceived barriers, and COVID-19-related disruptions in HCC surveillance in patients with cirrhosis. Data were analyzed from October to November 2023. Main Outcome and Measures HCC surveillance knowledge was assessed with 6 questions querying the respondent's ability to correctly identify appropriate use of HCC surveillance. Attitudes, perceived barriers, and beliefs regarding HCC surveillance and perceived impact of the COVID-19 pandemic-related disruptions with HCC surveillance were assessed with a series of statements using a 4-point Likert scale and compared PCCs and gastroenterology and hepatology clinicians. Results Overall, 347 of 1362 clinicians responded to the survey (25.5% response rate), among whom 142 of 237 (59.9%) were PCCs, 48 of 237 (20.3%) gastroenterology and hepatology, 190 of 236 (80.5%) were doctors of medicine and doctors of osteopathic medicine, and 46 of 236 (19.5%) were advanced practice clinicians. On HCC knowledge assessment, 144 of 270 (53.3%) scored 5 or more of 6 questions correctly, 37 of 48 (77.1%) among gastroenterology and hepatology vs 65 of 142 (45.8%) among PCCs (P < .001). Those with higher HCC knowledge scores were less likely to report barriers to HCC surveillance. PCCs were more likely to report inadequate time to discuss HCC surveillance (37 of 139 [26.6%] vs 2 of 48 [4.2%]; P = .001), difficulty identifying patients with cirrhosis (82 of 141 [58.2%] vs 5 of 48 [10.4%]; P < .001), and were not up-to-date with HCC surveillance guidelines (87 of 139 [62.6%] vs 5 of 48 [10.4%]; P < .001) compared with gastroenterology and hepatology clinicians. While most acknowledged delays during the COVID-19 pandemic, 62 of 136 PCCs (45.6%) and 27 of 45 gastroenterology and hepatology clinicians (60.0%) reported that patients with cirrhosis could currently complete HCC surveillance without delays. Conclusions and Relevance In this survey study, important gaps in knowledge and perceived barriers to HCC surveillance were identified. Effective delivery of HCC education to PCCs and health system-level interventions must be pursued in parallel to address the complex barriers affecting suboptimal HCC surveillance in patients with cirrhosis.
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Affiliation(s)
- Robert J. Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine and Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Patricia D. Jones
- Division of Digestive Health and Liver Diseases, University of Miami School of Medicine and Jackson Memorial Health System, Miami, Florida
| | - Bolin Niu
- Division of Gastroenterology and Hepatology, MetroHealth Hospital and Health System, Cleveland, Ohio
| | | | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Onkar Kshirsagar
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Yi Zhang
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Paulo Pinheiro
- Division of Epidemiology and Population Health Sciences, University of Miami School of Medicine, Miami, Florida
| | - Beverly Kyalwazi
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth Hospital and Health System, Cleveland, Ohio
| | - Mandana Khalili
- Division of Gastroenterology and Hepatology, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center and Parkland Health, Dallas
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7
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Malik MS, Subrize MW, Ou J, Curry MP, Parikh ND, Novack V, Weinstein JL, Ahmed M, Sarwar A. Association between Patient Experience Scores and Low Utilization of Hepatocellular Carcinoma Treatment in the United States: A Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems Analysis (SEER-CAHPS). J Vasc Interv Radiol 2024; 35:102-112.e5. [PMID: 37696431 DOI: 10.1016/j.jvir.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/30/2023] [Accepted: 09/02/2023] [Indexed: 09/13/2023] Open
Abstract
PURPOSE To study the experiences of patients with hepatocellular carcinoma (HCC) contributing to treatment discrepancy in the United States. MATERIALS AND METHODS Using Surveillance, Epidemiology, and End Results data from National Cancer Institute (NCI), Medicare (2002-2015) beneficiaries with HCC who completed a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey were included. Six CAHPS items (3 global scores: global care rating [GCR], primary doctor rating [PDR], and specialist rating [SR]; 3 composite scores: getting needed care [GNC], getting care quickly [GCQ], and doctor communication [DC]) assessed patient experience. Covariates assessed between treated and nontreated groups included patient, disease, hospital, and CAHPS items. RESULTS Among 548 patients with HCC, 211 (39%) received treatment and 337 (61%) did not receive treatment. Forty-two percent (GCR), 29% (PDR), 30% (SR), 36% (GNC), 78% (GCQ), and 35% (DC) of patients reported less-than-excellent experiences on the respective CAHPS items. Chronic liver disease (CLD) was present in 52% and liver decompensation (LD) in 60%. A minority of the hospitals were NCI-designated cancer centers (47%), transplant centers (27%), and referral centers (9%). On univariable analysis, patients with at least a high school degree (odds ratio [OR], 1.9), admittance to a ≥400-bed hospital (OR, 2.7), CLD (OR, 3.0), or LD (OR, 1.7) were more likely to receive treatment, whereas older patients (≥75 years) (OR, 0.5) were less likely to receive treatment. On multivariable, patients with CLD (OR, 6.8) and an excellent experience in GNC with a specialist (OR, 10.6) were more likely to receive treatment. CONCLUSIONS HCC treatment discrepancy may be associated with patient-related factors, such as lack of specialist care (GNC), and disease-related factors, such as absence of underlying CLD.
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Affiliation(s)
- M Saad Malik
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts.
| | - Michael W Subrize
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Jiangda Ou
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Michael P Curry
- Division of Gastroenterology & Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Neehar D Parikh
- Division of Gastroenterology & Hepatology, Department of Medicine, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Victor Novack
- Center for Healthcare Delivery Sciences, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Medicine, Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Jeffrey L Weinstein
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Muneeb Ahmed
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Ammar Sarwar
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
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8
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Beal EW, Owen M, McNamara M, McAlearney AS, Tsung A. Patient-, Provider-, and System-Level Barriers to Surveillance for Hepatocellular Carcinoma in High-Risk Patients in the USA: a Scoping Review. J Gastrointest Cancer 2023; 54:332-356. [PMID: 35879510 DOI: 10.1007/s12029-022-00851-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Hepatocellular carcinoma has a dismal prognosis, except in patients diagnosed early who are candidates for potentially curative therapies. Most HCC cases develop in patients with chronic liver disease. Therefore, expert society guidelines recommend surveillance every 6 months with ultrasound with or without serum alpha-fetoprotein for high-risk patients. However, fewer than 20% of patients in the USA undergo appropriate surveillance. METHODS A systematic scoping review was performed with the objective of identifying barriers to screening among high-risk patients in the USA including mapping key concepts in the relevant literature, identifying the main sources and types of evidence available, and identifying gaps in the literature. A total of 43 studies published from 2007 to 2021 were included. Data were extracted and a conceptual framework was created. RESULTS Assessment of quantitative studies revealed poor surveillance rates, often below 50%. Three categories of barriers to surveillance were identified: patient-level, provider-level, and system-level barriers. Prevalent patient-level barriers included financial constraints, lack of awareness of surveillance recommendations, and scheduling difficulties. Common provider-level barriers were lack of provider awareness of guidelines for surveillance, difficulty accessing specialty resources, and time constraints in the clinic. System-level barriers included fewer clinic visits and rural/safety-net settings. Proposed interventions include improved patient/provider education, patient navigators, increased community/academic collaboration, and EMR-based reminders. CONCLUSION Based on these findings, there is a crucial need to implement and evaluate proposed interventions to improve HCC surveillance.
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Affiliation(s)
- Eliza W Beal
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210, USA.
- The Center for the Advancement of Team Science, Systems Thinking in Health Services and Implementation Science Research (CATALYST, The Ohio State University College of Medicine, AnalyticsColumbus, OH, 43210, USA.
| | - Mackenzie Owen
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Molly McNamara
- The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Ann Scheck McAlearney
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210, USA
- The Center for the Advancement of Team Science, Systems Thinking in Health Services and Implementation Science Research (CATALYST, The Ohio State University College of Medicine, AnalyticsColumbus, OH, 43210, USA
- The Department of Family and Community Medicine, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Allan Tsung
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210, USA
- The Center for the Advancement of Team Science, Systems Thinking in Health Services and Implementation Science Research (CATALYST, The Ohio State University College of Medicine, AnalyticsColumbus, OH, 43210, USA
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9
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McMahon B, Cohen C, Brown Jr RS, El-Serag H, Ioannou GN, Lok AS, Roberts LR, Singal AG, Block T. Opportunities to address gaps in early detection and improve outcomes of liver cancer. JNCI Cancer Spectr 2023; 7:pkad034. [PMID: 37144952 PMCID: PMC10212536 DOI: 10.1093/jncics/pkad034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/10/2023] [Indexed: 05/06/2023] Open
Abstract
Death rates from primary liver cancer (hepatocellular carcinoma [HCC]) have continued to rise in the United States over the recent decades despite the availability of an increasing range of treatment modalities, including new systemic therapies. Prognosis is strongly associated with tumor stage at diagnosis; however, most cases of HCC are diagnosed beyond an early stage. This lack of early detection has contributed to low survival rates. Professional society guidelines recommend semiannual ultrasound-based HCC screening for at-risk populations, yet HCC surveillance continues to be underused in clinical practice. On April 28, 2022, the Hepatitis B Foundation convened a workshop to discuss the most pressing challenges and barriers to early HCC detection and the need to better leverage existing and emerging tools and technologies that could improve HCC screening and early detection. In this commentary, we summarize technical, patient-level, provider-level, and system-level challenges and opportunities to improve processes and outcomes across the HCC screening continuum. We highlight promising approaches to HCC risk stratification and screening, including new biomarkers, advanced imaging incorporating artificial intelligence, and algorithms for risk stratification. Workshop participants emphasized that action to improve early detection and reduce HCC mortality is urgently needed, noting concern that many of the challenges we face today are the same or similar to those faced a decade ago and that HCC mortality rates have not meaningfully improved. Increasing the uptake of HCC screening was identified as a short-term priority while developing and validating better screening tests and risk-appropriate surveillance strategies.
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Affiliation(s)
- Brian McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, AK, USA
| | | | - Robert S Brown Jr
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
| | - Hashem El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - George N Ioannou
- Department of Medicine, Division of Gastroenterology, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Anna S Lok
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lewis R Roberts
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Amit G Singal
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern, Dallas, TX, USA
| | - Timothy Block
- Baruch S. Blumberg Institute and Hepatitis B Foundation, Doylestown, PA, USA
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10
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King WW, Richhart R, Culpepper T, Mota M, Banerjee D, Ismael M, Chakraborty J, Ladna M, Khan W, Ruiz N, Wilson J, Altshuler E, Clark V, Cabrera R. Adherence to guideline-directed hepatocellular carcinoma screening: A single-center US experience. World J Hepatol 2023; 15:410-418. [PMID: 37034234 PMCID: PMC10075011 DOI: 10.4254/wjh.v15.i3.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/16/2023] [Accepted: 02/21/2023] [Indexed: 03/22/2023] Open
Abstract
BACKGROUND The American Association for the Study of Liver Disease recommends screening patients with cirrhosis for hepatocellular carcinoma (HCC) using imaging with or without alpha-fetoprotein every six months. Unfortunately, screening rates remain inadequate.
AIM To assess root causes of screening failure in a subspecialty hepatology clinic.
METHODS The authors identified patients with cirrhosis seen in a subspecialty hepatology clinic and determined whether they underwent appropriate screening, defined as two cross-sectional images between five and seven months apart. The authors characterized the primary driver of screening failure. Finally, other hepatologists were surveyed to determine provider perceptions of screening failure causes.
RESULTS 1034 patients were identified with an average age of 61 years and a mean MELD of 8.1 ± 3.8. Hepatitis C virus was the most common cirrhosis etiology. 489 (47%) underwent appropriate screening. No demographic or clinical differences were detected between those who underwent appropriate screening and those who did not. The most common etiologies of screening failure, in descending order, were: radiology unable to schedule timely imaging, provider did not order imaging, patient canceled follow up appointment, appointments scheduled too far apart, lost to follow up, no-show to radiology appointment, and provider canceled appointment. Hepatologists surveyed believed the most common cause of screening failure was no-show to radiology.
CONCLUSION Rates of screening were poor even in a subspecialty hepatology clinic. Screening failure was mostly due to systemic factors such as radiology availability and time between hepatology appointments rather than individual error.
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Affiliation(s)
- William W King
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Raymond Richhart
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Tyler Culpepper
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Maneola Mota
- Department of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
| | - Debdeep Banerjee
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Media Ismael
- Department of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
| | - Joydeep Chakraborty
- Department of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
| | - Michael Ladna
- Department of Hospital Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Walid Khan
- Department of Hospital Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Nicole Ruiz
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Jake Wilson
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Ellery Altshuler
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Virginia Clark
- Department of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
| | - Roniel Cabrera
- Department of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
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11
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Ramai D, Singh J, Chandan S, Tartaglia N, Ambrosi A, Khan SR, Sacco R, Facciorusso A. Utilization of Hepatocellular Carcinoma Surveillance Programs in Patients With Cirrhosis: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2023; 57:198-203. [PMID: 34999648 DOI: 10.1097/mcg.0000000000001668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/06/2021] [Indexed: 01/07/2023]
Abstract
Patients with cirrhosis are advised to undergo hepatocellular carcinoma (HCC) surveillance every 6 months. Routine surveillance is associated with early tumor detection and improved survival. However, surveillance is underutilized. We aimed to characterize the uptake of HCC surveillance in cirrhotic patients following the implementation of interventional programs. We performed a comprehensive literature search of major databases (from inception to October 2020). Surveillance was defined as having an abdominal sonogram every 6 months. Nine studies were included for meta-analysis which involved 4550 patients. The etiology of liver cirrhosis was largely due to hepatitis C or B (n=2023), followed by alcohol (n=857), and nonalcoholic steatohepatitis (n=432). Patients enrolled in surveillance programs were 6 times more likely to undergo abdominal sonography when compared with standard of care (odds ratio=6.00; 95% confidence interval: 3.35-10.77). On subgroup analysis, clinical reminders were associated with a 4 times higher rate of HCC surveillance compared with standard of care (odds ratio=3.80; 95% confidence interval: 2.25-6.39). Interventional programs significantly improve the rate of HCC surveillance. This is clinically impactful and should be considered as a means for improving surveillance rates.
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Affiliation(s)
- Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah, Salt Lake City, UT
| | - Jameel Singh
- Department of Internal Medicine, Mather Hospital, Northwell Health, Port Jefferson, NY
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Health Creighton University Medical Center, Omaha, NE
| | - Nicola Tartaglia
- Department of Surgical and Medical Sciences, General Surgery Unit
| | - Antonio Ambrosi
- Department of Surgical and Medical Sciences, General Surgery Unit
| | - Shahab R Khan
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Rodolfo Sacco
- Section of Internal Medicine, Hospital of Faenza, Faenza, Italy
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Surgical and Medical Sciences, University of Foggia, Foggia
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12
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Wong RJ, Jayasekera C, Jones P, Kanwal F, Singal AG, Ahmed A, Taglienti R, Younossi Z, Kulik L, Mehta N. An Open-Access, Interactive Decision-Support Tool to Facilitate Guideline-Driven Care for Hepatocellular Carcinoma. Gastroenterology Res 2022; 15:297-307. [PMID: 36660470 PMCID: PMC9822660 DOI: 10.14740/gr1573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/07/2022] [Indexed: 12/23/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is increasing in incidence and is a leading cause of cancer-related mortality worldwide. Adherence to HCC surveillance guidelines and appropriate treatment triage of liver lesions may improve receipt of curative-intent treatment and improved survival. Late-stage HCC diagnosis reflects sub-optimal implementation of effective HCC surveillance, whereas inappropriate treatment triage or linkage to care accounts for the non-receipt of curative-intent in close to half of early-stage HCC in the USA. A free, open-access decision-support tool for liver lesions that incorporates current guideline recommendations in a user-friendly interface could improve appropriate and timely triage of patients to appropriate care. This review provides a summary of gaps and disparities in linkage to HCC care and introduces a free, internet-based, interactive decision-support tool for managing liver lesions. This tool has been developed by the HCC Steering Committee of the Chronic Liver Disease Foundation and is targeted toward clinicians across specialties who may encounter liver lesions during routine care or as part of dedicated HCC surveillance.
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Affiliation(s)
- Robert J. Wong
- Veterans Affairs Palo Alto Healthcare System, Stanford University School of Medicine, Palo Alto, CA, USA,Corresponding Author: Robert J. Wong, Veterans Affairs Palo Alto Healthcare System, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
| | | | | | - Fasiha Kanwal
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Amit G. Singal
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aijaz Ahmed
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | - Neil Mehta
- University of California, San Francisco, CA, USA
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13
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Jaffe A, Taddei TH, Giannini EG, Ilagan-Ying YC, Colombo M, Strazzabosco M. Holistic management of hepatocellular carcinoma: The hepatologist's comprehensive playbook. Liver Int 2022; 42:2607-2619. [PMID: 36161463 PMCID: PMC10878125 DOI: 10.1111/liv.15432] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/26/2022] [Accepted: 09/21/2022] [Indexed: 12/12/2022]
Abstract
Hepatocellular carcinoma (HCC) is a common complication in patients with chronic liver disease and leads to significant morbidity and mortality. Liver disease and liver cancer are preventable by mitigating and managing common risk factors, including chronic hepatitis B and C infection, alcohol use, diabetes, obesity and other components of the metabolic syndrome. The management of patients with HCC requires treatment of the malignancy and adequate control of the underlying liver disease, as preserving liver function is critical for successful cancer treatment and may have a relevant prognostic role independent of HCC management. Hepatologists are the ideal providers to guide the care of patients with HCC as they are trained to identify patients at risk, apply appropriate surveillance strategies, assess and improve residual liver function, evaluate candidacy for transplant, provide longitudinal care to optimize and preserve liver function during and after HCC treatment, survey for cancer recurrence and manage its risk factors, and prevent and treat decompensating events. We highlight the need for a team-based holistic approach to the patient with liver disease and HCC and identify necessary gaps in current care and knowledge.
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Affiliation(s)
- Ariel Jaffe
- Liver Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Smilow Cancer Hospital and Liver Cancer Program, New Haven, CT, USA
| | - Tamar H. Taddei
- Liver Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Edoardo G. Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Ysabel C. Ilagan-Ying
- Liver Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Mario Strazzabosco
- Liver Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Smilow Cancer Hospital and Liver Cancer Program, New Haven, CT, USA
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14
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Chang SS, Hu HY, Cheng FS, Chen YC, Yen YF, Huang N. Factors associated with nonadherence to surveillance for hepatocellular carcinoma among patients with hepatic C virus cirrhosis, 2000-2015. Medicine (Baltimore) 2022; 101:e31907. [PMID: 36451463 PMCID: PMC9704922 DOI: 10.1097/md.0000000000031907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Hepatocellular carcinoma (HCC) surveillance can detect the early stage of tumors and lead to improved survival. Adherence to guideline-concordant HCC surveillance is crucial in at-risk populations, including patients with hepatic C virus (HCV) cirrhosis. This study was conducted to identify patient and provider factors associated with nonadherence to HCC surveillance in patients with HCV cirrhosis. Data were primarily obtained from the Taiwan National Health Insurance Research Database for the 2000 to 2015 period. Adult patients newly diagnosed as having HCV cirrhosis between 2003 and 2012 were enrolled. Each patient was followed up for 3 years and until the end of 2015. Annual HCC surveillance was defined as the uptake of an abdominal ultrasound and alpha-fetoprotein (AFP) test annually during the 3-years follow-up. Nonannual surveillance was defined as the lack of an annual abdominal ultrasound and AFP test during the same 3-years period. Multinomial logistic regression models were applied to determine factors influencing adherence or nonadherence to annual HCC surveillance. We included a total of 4641 patients with HCV cirrhosis for analysis. Of these patients, only 14% adhered to annual HCC surveillance. HCC surveillance improved in later years, compared with the earlier phases of the study period. Patients with HCV cirrhosis comorbid with coronary artery disease (CAD) or chronic obstructive pulmonary disease (COPD) or those with a relatively high number of comorbidities had a significantly higher likelihood of nonadherence. Patients who primarily received care from internists were significantly less likely to exhibit nonadherence to annual HCC surveillance compared with patients receiving care from physicians of other specialties. Patients who primarily received care from physicians practicing in larger hospitals were significantly less likely to exhibit nonadherence. HCC surveillance rates remain unacceptably low among high-risk patients, and our findings may be helpful in the development of effective interventions to increase HCC surveillance. The effective incorporation of HCC surveillance into routine visits for other chronic comorbidities, particularly for CAD or COPD, may be crucial for increasing HCC surveillance.
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Affiliation(s)
- Shen-Shong Chang
- Division of Gastroenterology
- Department of Internal Medicine; Taipei City Hospital Yang-Ming Branch
- Department of Medicine, School of Medicine
- Institute of Public Health and Department of Public Health
| | - Hsiao-Yun Hu
- Institute of Public Health and Department of Public Health
- Institute of Hospital and Health Care Administration; National Yang Ming Chiao Tung University
| | - Feng-Shiang Cheng
- Institute of Hospital and Health Care Administration; National Yang Ming Chiao Tung University
| | - Yu-Chin Chen
- Department of Education and Research; Taipei City Hospital
| | - Yung-Feng Yen
- Institute of Public Health and Department of Public Health
- Institute of Hospital and Health Care Administration; National Yang Ming Chiao Tung University
- Section of Infectious Diseases, Taipei City Hospital Yang-Ming Branch
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences
| | - Nicole Huang
- Department of Education and Research; Taipei City Hospital
- * Correspondence: Nicole Huang, Institute of Hospital and Health Care Administration, School of Medicine, National Yang Ming Chiao Tung University, Room 201, The Medical Building II, No. 155, Section 2, Li-Nong Street, Taipei 112, Taiwan (e-mail: )
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15
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Golriz M, Ramouz A, Ali-Hasan-Al-Saegh S, Shafiei S, Aminizadeh E, Hammad A, Mieth M, Rupp C, Springfeld C, Hoffmann K, Büchler M, Mehrabi A. Prognostic Value of Red Blood Cell Distribution Width (RDW) in the Recurrence of Hepatocellular Carcinoma Following Curative Resection. J Hepatocell Carcinoma 2022; 9:1137-1147. [PMID: 36338431 PMCID: PMC9635388 DOI: 10.2147/jhc.s380243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/06/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose Although surgery is associated with an acceptable cure rate, tumor recurrence is still a challenging issue in hepatocellular carcinoma (HCC) patients. Red blood cell distribution width (RDW) is considered an inflammatory marker for predicting overall mortality in a wide spectrum of malignancies. In the current study, the prognostic role of pre- and postoperative RDW in HCC recurrence after liver resection (LRx) is investigated. Patients and Methods In 395 patients, RDW levels were evaluated preoperatively as well as six and twelve months after curative LRx. The RDW cutoff values were determined using receiver operating characteristic curves (ROCs) according to the recurrence-free survival (RFS). Survival analyses were performed using the Kaplan-Meier, and differences were compared using the Log rank test. Results The RFS was significantly higher among patients with low RDW at the 6th month and 12th month, postoperatively (P < 0.001 and P = 0.028). RDW levels of higher than 16.15% at the 6th (HR: 2.047, P <0.001) and higher than 15.85% at 12th (HR: 3.105, P < 0.002) months after liver resection were independent predictors of RFS. Conclusion Postoperative RDW values seem to be predictive of tumor recurrence in HCC patients. RDW levels at the 6th and 12th months postoperatively were independent predictors of recurrence after LRx.
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Affiliation(s)
- Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany,Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Sadeq Ali-Hasan-Al-Saegh
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Saeed Shafiei
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Ehsan Aminizadeh
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Ahmed Hammad
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Markus Mieth
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Christian Rupp
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany,Department of Internal Medicine IV, Gastroenterology & Hepatology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Christoph Springfeld
- Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany,National Center for Tumor Diseases, Department of Medical Oncology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany,Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Markus Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany,Liver Cancer Center Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany,Correspondence: Arianeb Mehrabi, Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, Heidelberg, 69120, Germany, Tel +49–6221–5636223, Fax +49–6221–567470, Email
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16
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Walker PF, Settgast AM, DeSilva MB. Cancer Screening in Refugees and Immigrants: A Global Perspective. Am J Trop Med Hyg 2022; 106:tpmd210692. [PMID: 35533696 PMCID: PMC9209943 DOI: 10.4269/ajtmh.21-0692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 02/09/2022] [Indexed: 12/24/2022] Open
Abstract
Clinicians in the United States are trained to screen for cancer based on patient age, gender, family history, and environmental risk factors such as smoking. These cancers generally include, breast, cervical, colon, lung, and prostate cancers. We know that refugees and other immigrants to the United States experience dramatic disparities in cancer screening. Additionally, many immigrants experience elevated risks from infection-attributable cancers due to their country or region of origin. U.S.- based clinicians may not routinely consider these unique risk factors. Although this article focuses on refugees, it is also intended to guide clinicians caring for other foreign-born immigrant groups living in the United States (hereafter referred to as "immigrants"). The document contains two sections: 1) special considerations for U.S. Preventive Services Task Force guidelines cancer screening recommendations in immigrants and 2) cancer risks and screening recommendation unique to certain immigrant groups. Disparities in cancer screening and prevalence are often greater for specific immigrant groups than for broader racial or ethnic groups (e.g., Black, Asian, Hispanic) into which they may fit. Disaggregation of data by language or country of origin is useful to identify such disparities and to design intervention opportunities within specific communities that are culturally distinct and/or who have different environmental exposures. Unique cancer risks and disparities in screening support a nuanced approach to cancer screening for immigrant and refugee populations, which is the focus of this narrative review.
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Affiliation(s)
- Patricia F. Walker
- HealthPartners Institute, Bloomington, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- HealthPartners Travel and Tropical Medicine Center, St. Paul, Minnesota
| | - Ann M. Settgast
- HealthPartners Institute, Bloomington, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- HealthPartners Center for International Health, St. Paul, Minnesota
- HealthPartners Travel and Tropical Medicine Center, St. Paul, Minnesota
| | - Malini B. DeSilva
- HealthPartners Institute, Bloomington, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- HealthPartners Travel and Tropical Medicine Center, St. Paul, Minnesota
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17
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Dirchwolf M, Marciano S, Ruf AE, Singal AG, D'Ercole V, Coisson P, Zerega A, Orozco F, Palazzo A, Fassio E, Arufe D, Anders M, D'Amico C, Gaite L, Thompson M, Perez D, Haddad L, Demirdjian E, Zunino M, Gadano A, Murga MD, Bermudez C, Tomatis J, Grigera N, Antinucci F, Baravalle M, Gazari MMR, Ferreiro M, Barbero M, Curia A, Demonte M, Gualano G. Failure in all steps of hepatocellular carcinoma surveillance process is frequent in daily practice. Ann Hepatol 2022; 25:100344. [PMID: 33819695 DOI: 10.1016/j.aohep.2021.100344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Failures at any step in the hepatocellular carcinoma (HCC) surveillance process can result in HCC diagnostic delays and associated worse prognosis. We aimed to estimate the prevalence of surveillance failure and its associated risk factors in patients with HCC in Argentina, considering three steps: 1) recognition of at-risk patients, 2) implementation of HCC surveillance, 3) success of HCC surveillance. METHODS We performed a multi-center cross-sectional study of patients at-risk for HCC in Argentina seen between10.01.2018 and 10.30.2019. Multivariable logistic regression analysis was used to identify correlates of surveillance failure. RESULTS Of 301 included patients, the majority were male (74.8%) with a mean age of 64 years old. At the time of HCC diagnosis, 75 (25%) patients were unaware of their diagnosis of chronic liver disease, and only 130 (43%) patients were under HCC surveillance. Receipt of HCC surveillance was significantly associated with follow-up by a hepatologist. Of 119 patients with complete surveillance, surveillance failure occurred in 30 (25%) patients. Surveillance failure was significantly associated with alpha fetoprotein ≥20 ng/mL (OR 4.0, CI 95% 1.43-11.55). CONCLUSIONS HCC surveillance failure was frequent in all the evaluated steps. These data should help guide strategies to improve the implementation and results of HCC surveillance in our country.
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Affiliation(s)
| | | | - Andres E Ruf
- Hospital Privado de Rosario, Rosario, Santa Fe, Argentina
| | - Amit G Singal
- Department Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Vanina D'Ercole
- Hospital Complejo Médico de la Policía Federal Churruca - Visca, CABA, Argentina
| | - Paola Coisson
- Hospital El Cruce - Néstor Kirchner, Florencio Varela, Buenos Aires, Argentina
| | - Alina Zerega
- Sanatorio Allende, Córdoba, Córdoba, Argentina; Hospital Córdoba, Córdoba, Córdoba, Argentina
| | | | - Ana Palazzo
- Hospital Ángel C. Padilla, San Miguel de Tucumán, Tucumán, Argentina
| | - Eduardo Fassio
- Hospital Nacional Prof. Alejandro Posadas, El Palomar, Buenos Aires. Argentina
| | | | | | - Claudia D'Amico
- Centro Especialidades Médicas Ambulatoria, Mar del Plata, Buenos Aires, Argentina
| | - Luis Gaite
- Hospital José M. Cullen, Santa Fe, Santa Fe, Argentina; Clínica de Nefrología, Urología y Enfermedades Cardiovasculares, Santa Fe, Argentina
| | - Marcos Thompson
- Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Daniela Perez
- Hospital Ángel C. Padilla, San Miguel de Tucumán, Tucumán, Argentina
| | - Leila Haddad
- Hospital Italiano de Buenos Aires, CABA, Argentina
| | | | - Moira Zunino
- Hospital Ángel C. Padilla, San Miguel de Tucumán, Tucumán, Argentina
| | | | | | | | - Jesica Tomatis
- Hospital Privado de Rosario, Rosario, Santa Fe, Argentina
| | | | | | | | | | - Melina Ferreiro
- Hospital de Clínicas José de San Martín (UBA), CABA, Argentina
| | - Manuel Barbero
- Hospital El Cruce - Néstor Kirchner, Florencio Varela, Buenos Aires, Argentina
| | - Andrea Curia
- Hospital de Clínicas José de San Martín (UBA), CABA, Argentina
| | | | - Gisela Gualano
- Hospital Nacional Prof. Alejandro Posadas, El Palomar, Buenos Aires. Argentina
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18
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Del Poggio P, Mazzoleni M, Lazzaroni S, D'Alessio A. Surveillance for hepatocellular carcinoma at the community level: Easier said than done. World J Gastroenterol 2021; 27:6180-6190. [PMID: 34712026 PMCID: PMC8515795 DOI: 10.3748/wjg.v27.i37.6180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/24/2021] [Accepted: 08/10/2021] [Indexed: 02/06/2023] Open
Abstract
Surveillance for hepatocellular carcinoma (HCC) in high-risk patients with semiannual ultrasound examinations is advocated by all international guidelines. However, as long as the identification of the population to be screened and the surveillance programs are not well implemented, the real-life impact of HCC surveillance in reducing mortality for HCC cannot be known. We propose a new approach that promotes the identification of cirrhotic patients by primary care physicians (PCPs) and referral of patients to the hepatologist for surveillance. Surveillance should be incorporated, when feasible, in a hub and spoke model of comprehensive hepatology care. Training PCPs to identify cirrhotic patients and performing surveillance in a subspecialist setting are equally important to improve the effectiveness of real-life surveillance and to decrease HCC mortality over time.
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Affiliation(s)
- Paolo Del Poggio
- Unità di Epatologia, Policlinico San Marco Zingonia GSD University and Research Hospital Unità Epatologia, Osio Sotto 24040, Bergamo, Italy
| | - Marzio Mazzoleni
- Primary Care Physician, ASST Bergamo, Osio Sotto 24040, Bergamo, Italy
| | - Sergio Lazzaroni
- Unità di Epatologia, Policlinico San Marco Zingonia GSD University and Research Hospital Unità Epatologia, Osio Sotto 24040, Bergamo, Italy
| | - Andrea D'Alessio
- Department of Medicine, Policlinico San Marco Zingonia, GSD University and Research Hospital, Osio Sotto 24040, Bergamo, Italy
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19
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Rao A, Rich NE, Marrero JA, Yopp AC, Singal AG. Diagnostic and Therapeutic Delays in Patients With Hepatocellular Carcinoma. J Natl Compr Canc Netw 2021; 19:1063-1071. [PMID: 34077908 DOI: 10.6004/jnccn.2020.7689] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 11/23/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Delays in diagnosis and treatment have been reported for many cancers, with resultant stage migration and worse survival; however, few data exist in patients with hepatocellular carcinoma (HCC). These data are of particular importance in light of the COVID-19 pandemic, which has caused disruptions in healthcare processes and may continue to impact cancer care for the foreseeable future. The aim of our study was to characterize the prevalence and clinical significance of diagnostic and treatment delays in patients with HCC. METHODS We performed a retrospective cohort study of consecutive patients diagnosed with HCC between January 2008 and July 2017 at 2 US health systems. Diagnostic and treatment delays were defined as >90 days between presentation and HCC diagnosis and between diagnosis and treatment, respectively. We used multivariable logistic regression to identify factors associated with diagnostic and treatment delays and Cox proportional hazard models to identify correlates of overall survival. RESULTS Of 925 patients with HCC, 39.0% were diagnosed via screening, 33.1% incidentally, and 27.9% symptomatically. Median time from presentation to diagnosis was 37 days (interquartile range, 18-94 days), with 120 patients (13.0%) experiencing diagnostic delays. Median time from HCC diagnosis to treatment was 46 days (interquartile range, 29-74 days), with 17.2% of patients experiencing treatment delays. Most (72.5%) diagnostic delays were related to provider-level factors (eg, monitoring indeterminate nodules), whereas nearly half (46.2%) of treatment delays were related to patient-related factors (eg, missed appointments). In multivariable analyses, treatment delays were not associated with increased mortality (hazard ratio, 0.90; 95% CI, 0.60-1.35); these results were consistent across subgroup analyses by Barcelona Clinic Liver Cancer stage and treatment modality. CONCLUSIONS Diagnostic and therapeutic delays exceeding 3 months are common in patients with HCC; however, observed treatment delays do not seem to significantly impact overall survival.
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Affiliation(s)
| | - Nicole E Rich
- 1Department of Internal Medicine.,2Harold C. Simmons Comprehensive Cancer Center
| | - Jorge A Marrero
- 1Department of Internal Medicine.,3Department of Population and Data Sciences, and
| | - Adam C Yopp
- 2Harold C. Simmons Comprehensive Cancer Center.,4Department of Surgery, UT Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Texas
| | - Amit G Singal
- 1Department of Internal Medicine.,2Harold C. Simmons Comprehensive Cancer Center.,3Department of Population and Data Sciences, and
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20
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Lubel JS, Roberts SK, Howell J, Ward J, Shackel NA. Current issues in the prevalence, diagnosis and management of hepatocellular carcinoma in Australia. Intern Med J 2021; 51:181-188. [DOI: 10.1111/imj.15184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 12/19/2022]
Affiliation(s)
- John S. Lubel
- Department of Gastroenterology Alfred Hospital Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Stuart K. Roberts
- Department of Gastroenterology Alfred Hospital Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Jessica Howell
- Department of Gastroenterology St Vincent's Hospital Melbourne Melbourne Victoria Australia
- Department of Medicine University of Melbourne Melbourne Victoria Australia
- Disease Elimination Program Burnet Institute Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia
| | - James Ward
- School of Public Health University of Queensland Brisbane Queensland Australia
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21
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Wolf E, Rich NE, Marrero JA, Parikh ND, Singal AG. Use of Hepatocellular Carcinoma Surveillance in Patients With Cirrhosis: A Systematic Review and Meta-Analysis. Hepatology 2021; 73:713-725. [PMID: 32383272 PMCID: PMC7648722 DOI: 10.1002/hep.31309] [Citation(s) in RCA: 206] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/21/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Hepatocellular carcinoma (HCC) surveillance is associated with early tumor detection and improved survival; however, it is often underused in clinical practice. We aimed to characterize surveillance use among patients with cirrhosis and the efficacy of interventions to increase surveillance. APPROACH AND RESULTS We performed a systematic literature review using the MEDLINE database from January 2010 through August 2018 to identify cohort studies evaluating HCC surveillance receipt or interventions to increase surveillance in patients with cirrhosis. A pooled estimate for surveillance receipt with 95% confidence intervals was calculated. Correlates of surveillance use were defined from each study and prespecified subgroup analyses. Twenty-nine studies, with a total of 118,799 patients, met inclusion criteria, with a pooled estimate for surveillance use of 24.0% (95% confidence interval, 18.4-30.1). In subgroup analyses, the highest surveillance receipt was reported in studies with patients enrolled from subspecialty gastroenterology/hepatology clinics and lowest in studies characterizing surveillance in population-based cohorts (73.7% versus 8.8%, P < 0.001). Commonly reported correlates of surveillance included higher receipt among patients followed by subspecialists and lower receipt among those with alcohol-associated or nonalcoholic steatohepatitis (NASH)-related cirrhosis. All eight studies (n = 5,229) evaluating interventions including patient/provider education, inreach (e.g., reminder and recall systems), and population health outreach strategies reported significant increases (range 9.4%-63.6%) in surveillance receipt. CONCLUSIONS HCC surveillance remains underused in clinical practice, particularly among patients with alcohol-associated or NASH-related cirrhosis and those not followed in subspecialty gastroenterology clinics. Interventions such as provider education, inreach including reminder systems, and population health outreach efforts can significantly increase HCC surveillance.
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Affiliation(s)
- Erin Wolf
- Department of Internal MedicineUT Southwestern Medical CenterDallasTXUSA
| | - Nicole E Rich
- Department of Internal MedicineUT Southwestern Medical CenterDallasTXUSA
| | - Jorge A Marrero
- Department of Internal MedicineUT Southwestern Medical CenterDallasTXUSA
| | - Neehar D Parikh
- Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Amit G Singal
- Department of Internal MedicineUT Southwestern Medical CenterDallasTXUSA
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22
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Does Hepatocellular Carcinoma Surveillance Increase Survival in At-Risk Populations? Patient Selection, Biomarkers, and Barriers. Dig Dis Sci 2020; 65:3456-3462. [PMID: 32860090 PMCID: PMC7669568 DOI: 10.1007/s10620-020-06550-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatocellular carcinoma (HCC) is a highly morbid and prevalent cancer globally. While high quality evidence for mortality benefit of HCC surveillance is lacking, early detection of HCC is likely beneficial as prognosis is highly correlated with tumor stage. High risk populations, including patients with cirrhosis and subgroups with Hepatitis B, should undergo surveillance with ultrasound ± alpha-fetoprotein (AFP) at 6-month intervals. In addition, emerging data suggest that patients with Hepatitis C cirrhosis who achieve sustained virologic response should continue surveillance. Further research is needed to determine the value of surveillance in patients with nonalcoholic fatty liver disease in the absence of cirrhosis or with advanced fibrosis of other etiologies. Newer biomarkers and models such as Lens culinaris agglutinin-reactive fraction of AFP, des-γ-carboxy prothrombin, and the GALAD score are increasingly utilized in the diagnosis and prognostication of HCC. The role of these biomarkers in surveillance is still under investigation but may potentially offer a more practical alternative to traditional image-based surveillance. Despite recommendations from multiple professional society guidelines, many at-risk patients do not receive HCC surveillance due to barriers at the patient, clinician, and health care system levels. Strategies such as implementing patient navigation services, educating clinicians about surveillance guidelines, and creating automated outreach systems, may improve surveillance rates and ultimately reduce morbidity and mortality from HCC.
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23
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Chen Q, Ayer T, Adee MG, Wang X, Kanwal F, Chhatwal J. Assessment of Incidence of and Surveillance Burden for Hepatocellular Carcinoma Among Patients With Hepatitis C in the Era of Direct-Acting Antiviral Agents. JAMA Netw Open 2020; 3:e2021173. [PMID: 33206188 PMCID: PMC7675109 DOI: 10.1001/jamanetworkopen.2020.21173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE In the US, hepatocellular carcinoma (HCC), primarily associated with hepatitis C virus (HCV) infection, is the fastest rising cause of cancer-related death. Wider use of highly effective direct-acting antiviral agents (DAAs) substantially reduces the burden of chronic HCV infection, but the subsequent impacts with HCV-associated HCC remain unknown. OBJECTIVE To assess projected changes in the incidence rate of and surveillance burden for HCC in the era of DAA treatment for HCV. DESIGN, SETTING, AND PARTICIPANTS This decision analytical model study was performed from January 2019 to February 2020, using an individual-level state-transition simulation model to simulate disease progression, screening, and different waves of antiviral treatments for HCV in the US from 2012 to 2040. INTERVENTIONS Current clinical management for chronic HCV infection. MAIN OUTCOMES AND MEASURES Model outcomes were projected temporal trends and age distribution of incident HCC cases and candidates for HCC surveillance among patients with viremia and patients with virologically cured HCV. RESULTS The simulation model projected that the annual incidence of HCC among patients with viremia and patients with virologically cured HCV will continue increasing to 24 000 (95% uncertainty interval [UI], 18 000-31 000) cases until 2021. In patients with virologically cured HCV, incident HCC cases are projected to increase from 1000 (95% UI, 500-2100) in 2012 to the peak of 7000 (95% UI, 5000-9600) in 2031 with a subsequent decrease to 6000 (95% UI, 4300-8300) by 2040. The proportion of incident HCC cases that occur in individuals with virologically cured HCV is estimated to increase from 5.3% in 2012 to 45.8% in 2040. The number of candidates for HCC surveillance in the population with virologically cured HCV is projected to increase from 106 000 (95% UI, 70 000-178 000) in 2012 to the peak of 649 000 (95% UI, 512 000-824 000) in 2030 and decrease to 539 000 (95% UI, 421 000-687 000) by 2040, while the proportion of all candidates for surveillance who are virologically cured is estimated to increase from 8.5% to 64.6% during the same period. The average age of HCC incidence and surveillance candidates is estimated to increase from 55 in 2012 to 72 and 71, respectively, by 2040. CONCLUSIONS AND RELEVANCE The results of this study suggest that the burden of HCC will shift from patients with viremia to patients with virologically cured HCV, and to older populations. Appropriate management may be warranted for early detection of HCC in patients who may no longer be receiving specialty care for liver conditions.
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Affiliation(s)
- Qiushi Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston
- Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Turgay Ayer
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta
| | - Madeline G. Adee
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Xiaojie Wang
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta
| | - Fasiha Kanwal
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston
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24
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Understanding Gaps in the Hepatocellular Carcinoma Cascade of Care: Opportunities to Improve Hepatocellular Carcinoma Outcomes. J Clin Gastroenterol 2020; 54:850-856. [PMID: 33030855 DOI: 10.1097/mcg.0000000000001422] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality. Existing studies have highlighted significant disparities in HCC outcomes, particularly among vulnerable populations, including ethnic minorities, safety-net populations, underinsured patients, and those with low socioeconomic status and high risk behaviors. The majority of these studies have focused on HCC surveillance. Although HCC surveillance is one of the most important first steps in HCC monitoring and management, it is only one step in the complex HCC cascade of care that evolves from surveillance to diagnosis and tumor staging that leads to access to HCC therapies. In this current review, we explore the disparities that exist along this complex HCC cascade of care and further highlight potential interventions that have been implemented to improve HCC outcomes. These interventions focus on patient, provider, and system level factors and provide a potential framework for health systems to implement quality improvement initiatives to improve HCC monitoring and management.
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25
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Mahfouz M, Nguyen H, Tu J, Diaz CR, Anjan S, Brown S, Bosire K, Carrasquillo O, Martin P, Jones PD. Knowledge and Perceptions of Hepatitis B and Hepatocellular Carcinoma Screening Guidelines Among Trainees: A Tale of Three Centers. Dig Dis Sci 2020; 65:2551-2561. [PMID: 31813133 DOI: 10.1007/s10620-019-05980-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatitis B (HBV), the leading cause of hepatocellular carcinoma (HCC) worldwide, disproportionately affects minorities in the USA. Undiagnosed HBV precludes HCC screening and contributes to late-stage cancer presentation and decreased survival. Barriers to HBV and HCC screening include lack of insurance and limited diffusion of guidelines. We aimed to assess knowledge about HBV and HCC screening indications and explore barriers to screening. METHODS We surveyed trainees from the University of Miami/Jackson Memorial Hospitals, Palmetto General Hospital, and Mount Sinai Medical Center. We assessed knowledge using clinical vignettes. We performed bivariate and Chi-squared analyses. RESULTS There were 183 respondents; median age was 31 and 52% were male. The sample was 35% Hispanic, 29% White, 18% Asian, and 9% Black. Training department was Internal Medicine, 71%; Family Medicine, 11%; Infectious Diseases, 6%; or Gastroenterology, 7%. Only 59% correctly estimated national HBV prevalence; 25% correctly estimated global prevalence. In vignettes with behavioral risk factors, trainees correctly advised screening, 63-96%. However, when the risk factor was the birthplace, correct responses ranged from 33 to 53%. Overall, 45% chose an incorrect combination of HBV screening tests. Perceived barriers to screening included limited expertise in screening of immigrants and limited patient education. Respondents were more likely to recommend HCC screening in cirrhotic patients versus non-cirrhotic HBV patients. Key barriers to HCC screening included uncertainty about HCC guidelines and patient financial barriers. CONCLUSIONS Knowledge of HBV and HCC screening recommendations is suboptimal among trainees. Efforts to broadly disseminate HBV and HCC guidelines through targeted educational interventions are needed.
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Affiliation(s)
- Mahmoud Mahfouz
- Department of Medicine, Mount Sinai Medical Center, Miami, USA
| | - Harry Nguyen
- Department of Medicine, Palmetto General Hospital, Hialeah, USA
| | - Jonathan Tu
- University of Miami Miller School of Medicine, Miami, USA
| | - Carlos R Diaz
- Department of Medicine, University of Miami Miller School of Medicine, Miami, USA.,Jackson Memorial Hospital, Miami, USA
| | - Shweta Anjan
- Department of Medicine, Infectious Diseases Division, University of Miami Miller School of Medicine, Miami, USA
| | - Stefanie Brown
- Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Kassandra Bosire
- Department of Family Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Olveen Carrasquillo
- Department of Medicine, University of Miami Miller School of Medicine, Miami, USA.,Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, USA
| | - Paul Martin
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, USA.,Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Patricia D Jones
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, USA. .,Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA.
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26
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Ispas S, So S, Toy M. Barriers to Disease Monitoring and Liver Cancer Surveillance Among Patients with Chronic Hepatitis B in the United States. J Community Health 2020; 44:610-625. [PMID: 30539329 DOI: 10.1007/s10900-018-00604-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic hepatitis B infection (CHB) is a condition that needs ongoing care such as monitoring for liver enzymes (ALT) and HBV DNA tests in treated and untreated patients, and annual imaging evaluation for liver cancer. Although follow-up care and treatment might seem straight forward, an estimated two-thirds of those who are aware of their infection are not seeing a health care provider, and more than half of those who are eligible for treatment do not receive it. This study aimed to compile and examine studies related to the barriers of disease monitoring, treatment, and liver cancer surveillance for CHB patients in the United States (US). A total of 4439 studies on monitoring and surveillance of CHB published between 2007 and 2018 were identified through a search of electronic databases. After critical assessment, the authors included 42 studies, divided into categories: 'patient-related barriers'; 'provider-related barriers'; and 'system-related barriers'. Among the patient-related barriers, one of the most frequent factors invoked in failing to have adequate surveillance was lack of patient's knowledge. In the provider-related barrier category, a lack of disease knowledge and adherence to guidelines was frequently reported. For the system-related barrier category, the only recurrent mention was a lack of clarity in guidelines or lack of guidelines from certain national institutions. This review summarizes and highlights the need for long-term disease management improvement of chronic hepatitis B infection for patients and healthcare providers that care for them.
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Affiliation(s)
- Simona Ispas
- Asian Liver Center, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, CJ 130, Palo Alto, CA, 94304-5787, USA
| | - Samuel So
- Asian Liver Center, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, CJ 130, Palo Alto, CA, 94304-5787, USA
| | - Mehlika Toy
- Asian Liver Center, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, CJ 130, Palo Alto, CA, 94304-5787, USA.
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27
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Abara WE, Spradling P, Zhong Y, Moorman A, Teshale EH, Rupp L, Gordon SC, Schmidt M, Boscarino JA, Daida YG, Holmberg SD. Hepatocellular Carcinoma Surveillance in a Cohort of Chronic Hepatitis C Virus-Infected Patients with Cirrhosis. J Gastrointest Cancer 2020; 51:461-468. [PMID: 31124041 PMCID: PMC6874701 DOI: 10.1007/s12029-019-00255-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Six-monthly hepatocellular carcinoma (HCC) screening in cirrhotic patients has been recommended since 2011. HCC prognosis is associated with diagnosis at an early stage. We examined the prevalence and correlates of 6-monthly HCC surveillance in a cohort of HCV-infected cirrhotic patients. METHODS Data were obtained from the medical records of patients receiving care from four hospitals between January 2011 and December 2016. Frequencies and logistic regression were conducted. RESULTS Of 2,933 HCV-infected cirrhotic patients, most were ≥ 60 years old (68.5%), male (62.2%), White (65.8%), and had compensated cirrhosis (74.2%). The median follow-up period was 3.5 years. Among these patients, 10.9% were consistently screened 6 monthly and 21.4% were never screened. Patients with a longer history of cirrhosis (AOR = 0.86, 95% CI = 0.80-0.93) were less likely to be screened 6 monthly while decompensated cirrhotic patients (AOR = 1.39, 95% CI = 1.06-1.81) and cirrhotic patients between 18 and 44 years (AOR = 2.01, 95% CI = 1.07-3.74) were more likely to be screened 6 monthly compared to compensated cirrhotic patients and patients 60 years and older respectively. There were no significant differences by race, gender, or insurance type. CONCLUSION The prevalence of consistent HCC surveillance remains low despite formalized recommendations. One in five patients was never surveilled. Patients with a longer history of cirrhosis were less likely to be surveilled consistently despite their greater HCC risk. Improving providers' knowledge about current HCC surveillance guidelines, educating patients about the benefits of consistent HCC surveillance, and systemic interventions like clinical reminders and standing HCC surveillance protocols can improve guideline-concordant surveillance in clinical practice.
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Affiliation(s)
- Winston E Abara
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA.
| | - P Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
| | - Y Zhong
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
| | - A Moorman
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
| | - E H Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
| | - L Rupp
- Henry Ford Hospital, Detroit, MI, USA
| | | | - M Schmidt
- Kaiser Permanente Northwest, Portland, OR, USA
| | | | - Y G Daida
- Kaiser Permanente, Hawaii, Honolulu, HI, USA
| | - S D Holmberg
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop G-37, Atlanta, GA, 30333, USA
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28
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Disparities in Hepatocellular Carcinoma Surveillance: Dissecting the Roles of Patient, Provider, and Health System Factors. J Clin Gastroenterol 2020; 54:218-226. [PMID: 31913877 DOI: 10.1097/mcg.0000000000001313] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide and remains one of the most rapidly rising cancers among the US adults. While overall HCC survival is poor, early diagnosis via timely and consistent implementation of routine HCC surveillance among at-risk individuals leads to earlier tumor stage at diagnosis, which is directly correlated with improved options for potentially curative therapies, translating into improved overall survival. Despite this well-established understanding of the benefits of HCC surveillance, surveillance among cirrhosis patients remains suboptimal in a variety of practice settings. While the exact reasons underlying the unacceptably low rates of routine HCC surveillance are complex, it likely reflects multifactorial contributions at the patient, provider, and health care system levels. Furthermore, these multilevel challenges affect ethnic minorities disproportionately, which is particularly concerning given that ethnic minorities already experience existing barriers in timely access to consistent medical care, and these populations are disproportionately affected by HCC burden in the United States. In this review, we provide an updated evaluation of the existing literature on rates of HCC surveillance in the United States. We specifically highlight the existing literature on the impact of patient-specific, provider-specific, and health care system-specific factors in contributing to challenges in effective implementation of HCC surveillance.
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29
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Singal AG, Lampertico P, Nahon P. Epidemiology and surveillance for hepatocellular carcinoma: New trends. J Hepatol 2020; 72:250-261. [PMID: 31954490 PMCID: PMC6986771 DOI: 10.1016/j.jhep.2019.08.025] [Citation(s) in RCA: 753] [Impact Index Per Article: 150.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
The burden of hepatocellular carcinoma (HCC) is highest in East Asia and Africa, although its incidence and mortality are rapidly rising in the United States and Europe. With the implementation of hepatitis B vaccination and hepatitis C treatment programmes worldwide, the epidemiology of HCC is shifting away from a disease predominated by viral hepatitis - an increasing proportion of cases are now attributable to non-alcoholic steatohepatitis. Surveillance using ultrasound, with or without alpha-fetoprotein, every 6 months has been associated with improved early detection and improved overall survival; however, limitations in implementation lead to a high proportion of HCC being detected at late stages in clinical practice. Herein, we review the current state of HCC surveillance and highlight areas for future research, including improved risk stratification of at-risk patients, surveillance tools with higher sensitivity and specificity for early HCC, and interventions to increase surveillance utilisation.
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Affiliation(s)
- Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Pietro Lampertico
- CRC "A. M. and A. Migliavacca" Center for the Study of Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Pierre Nahon
- Centre de Recherche des Cordeliers, Sorbonne Universités, Université Paris Descartes, Université Paris Diderot, Université Paris, Paris, France; Functional Genomics of Solid Tumors, USPC, Université Paris Descartes, Université Paris Diderot, Université Paris, Paris, France; Service d'hépatologie, Hôpital Jean Verdier, Hôpitaux Universitaires Paris-Seine-Saint-Denis, Assistance-Publique Hôpitaux de Paris, Bondy, France; Unité de Formation et de Recherche Santé Médecine et Biologie Humaine, Université Paris 13, Communauté d'Universités et Etablissements Sorbonne Paris Cité, Paris, France
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30
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Torgersen J, Taddei TH, Park LS, Carbonari DM, Kallan MJ, Mitchell Richards K, Zhang X, Jhala D, Bräu N, Homer R, D'Addeo K, Mehta R, Skanderson M, Kidwai-Khan F, Justice AC, Lo Re V. Differences in Pathology, Staging, and Treatment between HIV + and Uninfected Patients with Microscopically Confirmed Hepatocellular Carcinoma. Cancer Epidemiol Biomarkers Prev 2020; 29:71-78. [PMID: 31575557 PMCID: PMC6980754 DOI: 10.1158/1055-9965.epi-19-0503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/21/2019] [Accepted: 09/25/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The incidence of hepatocellular carcinoma (HCC) is substantially higher among HIV-infected (HIV+) than uninfected persons. It remains unclear if HCC in the setting of HIV infection is morphologically distinct or more aggressive. METHODS We evaluated differences in tumor pathology in a cohort of HIV+ and uninfected patients with microscopically confirmed HCC in the Veterans Aging Cohort Study from 2000 to 2015. We reviewed pathology reports and medical records to determine Barcelona Clinic Liver Cancer stage (BCLC), HCC treatment, and survival by HIV status. Multivariable Cox regression was used to determine the hazard ratio [HR; 95% confidence interval (CI)] of death associated with HIV infection after microscopic confirmation. RESULTS Among 873 patients with HCC (399 HIV+), 140 HIV+ and 178 uninfected persons underwent liver tissue sampling and had microscopically confirmed HCC. There were no differences in histologic features of the tumor between HIV+ and uninfected patients, including tumor differentiation (well differentiated, 19% vs. 28%, P = 0.16) and lymphovascular invasion (6% vs. 7%, P = 0.17) or presence of advanced hepatic fibrosis (40% vs. 39%, P = 0.90). There were no differences in BCLC stage (P = 0.06) or treatment (P = 0.29) by HIV status. After adjustment for risk factors, risk of death was higher among HIV-infected than uninfected patients (HR = 1.37; 95% CI, 1.02-1.85). CONCLUSIONS We found no differences in HCC tumor characteristics or background hepatic parenchyma by HIV status, yet HIV was associated with poorer survival. Of note, pathology reports often omitted these characteristics. IMPACT Systematic evaluation of HCC pathology by HIV status is needed to understand tumor characteristics associated with improved survival.
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Affiliation(s)
- Jessie Torgersen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tamar H Taddei
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lesley S Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California
| | - Dean M Carbonari
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Xuchen Zhang
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Darshana Jhala
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Norbert Bräu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- James J. Peters VA Medical Center, Bronx, New York
| | - Robert Homer
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Kathryn D'Addeo
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Rajni Mehta
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Melissa Skanderson
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Farah Kidwai-Khan
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Amy C Justice
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Vincent Lo Re
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Yu JR, Wang J, Bhuket T, Liu B, Wong RJ. The Impact of Ethnic Subgroups on Tumor Stage at Diagnosis, Treatment Received, and Long-Term Survival Among Asian Adults With Hepatocellular Carcinoma. J Clin Exp Hepatol 2019; 9:182-190. [PMID: 31024200 PMCID: PMC6477129 DOI: 10.1016/j.jceh.2018.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/30/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND & AIMS Hepatocellular carcinoma (HCC) outcomes among Asians may differ by the Asian ethnic subgroup. We aim to evaluate the impact of the Asian ethnic subgroup on HCC tumor stage, treatment received, and overall survival among US adults. METHODS Using the 2004-2012 Surveillance, Epidemiology, and End Results U.S. cancer registry, we retrospectively evaluated disparities in HCC tumor stage at diagnosis, HCC treatment received, and overall survival among Asian adults, stratified by Asian ethnic subgroups. Multivariate regression models evaluated the independent impact of Asian ethnic subgroups on the HCC tumor stage at diagnosis, treatment received, and overall long-term survival. RESULTS Among 8160 Asians with HCC, Southeast Asian (SEA) patients accounted for 26% of all HCC, followed by Chinese (CH) (22%), and Filipinos (FP) (14.0%) patients. Japanese (JP) patients were significantly older than those of the other subgroups (mean 71.1, SD 10.8, P < 0.01). When evaluating HCC stage, FP patients were less likely to have localized HCC and less likely to have HCC within the Milan criteria than CH HCC patients. When evaluating HCC treatment, pacific islanders (PI), FP and SEA patients were significantly less likely to any receive HCC treatment than CH patients. Overall five-year HCC survival was highest among CH HCC patients (33.1%) and lowest among FP (19.9%) and JP patients (22.0%). CONCLUSION Among Asians with HCC in the US, significant disparities among Asian ethnic subgroups exist. More advanced disease was seen among FP patients, less HCC treatment was seen among FP and SEA patients, and significantly higher mortality was seen among FP, SEA, and JP patients with HCC.
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Key Words
- Asians
- CH, Chinese
- Epidemiology, and End Results
- FP, Filipino
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- JP, Japanese
- KR, Korean
- Milan criteria
- NAFLD, nonalcoholic fatty liver disease
- PI, Pacific Islander
- SA, South Asian
- SEA, Southeast Asian
- SEER
- SEER, Surveillance
- TACE, transarterial chemoembolization
- hepatocellular carcinoma
- liver cancer
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Affiliation(s)
- Justin R. Yu
- Department of Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Jennifer Wang
- Department of Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Taft Bhuket
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, USA
| | - Benny Liu
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, USA
| | - Robert J. Wong
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, USA
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Simmons OL, Feng Y, Parikh ND, Singal AG. Primary Care Provider Practice Patterns and Barriers to Hepatocellular Carcinoma Surveillance. Clin Gastroenterol Hepatol 2019; 17:766-773. [PMID: 30056183 PMCID: PMC7212522 DOI: 10.1016/j.cgh.2018.07.029] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/14/2018] [Accepted: 07/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Low rates of hepatocellular carcinoma (HCC) surveillance are primarily due to provider-related process failures. However, few studies have evaluated primary care provider (PCP) practice patterns, attitudes, and barriers to HCC surveillance at academic tertiary care referral centers. METHODS We conducted a web-based survey of PCPs at 2 tertiary care referral centers (133 providers) from June 2017 through December 2017. The survey was adapted from pretested surveys and included questions about practice patterns, attitudes, and barriers to HCC surveillance. We used the Fisher exact and Mann-Whitney rank-sum tests to identify factors associated with adherence to HCC surveillance recommendations, for categoric and continuous variables, respectively. RESULTS We obtained a provider-level response rate of 75% and clinic-level response rate of 100% (133 providers). Whereas most PCPs performed HCC surveillance themselves, one-third deferred surveillance to subspecialists and referred patients to a hepatology clinic. Providers believed the combination of ultrasound and α-fetoprotein analysis to be highly effective for early stage tumor detection and reported using the combination for assessment of most patients. However, PCPs were more likely to use computed tomography- or magnetic resonance imaging-based surveillance for patients with nonalcoholic steatohepatitis or decompensated cirrhosis. Most providers believed HCC surveillance to be efficacious for early tumor detection and increasing survival. However, they desired increased high-quality evidence to characterize screening benefits and harms. Providers expressed notable misconceptions about HCC surveillance, including the role for measurement of liver enzyme levels in HCC surveillance and cost effectiveness of surveillance in patients without cirrhosis. They also reported barriers, including not being up to date on HCC surveillance recommendations, limited time in the clinic, and competing clinical concerns. CONCLUSIONS In a web-based survey, PCPs reported misconceptions and barriers to HCC surveillance. This indicates the need for interventions, including provider education, to improve HCC surveillance effectiveness in clinical practice.
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Affiliation(s)
- Okeefe L. Simmons
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yuan Feng
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Amit G. Singal
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
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Im S, Jang ES, Lee JH, Lee CS, Kim BH, Chung JW, Kim JW, Jeong SH. Surveillance Rate and its Impact on Survival of Hepatocellular Carcinoma Patients in South Korea: A Cohort Study. Cancer Res Treat 2019; 51:1357-1369. [PMID: 30744319 PMCID: PMC6790861 DOI: 10.4143/crt.2018.430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 02/07/2019] [Indexed: 02/07/2023] Open
Abstract
Purpose Though regular surveillance of hepatocellular carcinoma (HCC) for high-risk patients is widely recommended, its rate and effectiveness are not clear. The aim of this study is to investigate the actual rate of HCC surveillance and its related factors and to clarify its impact on survival in a Korean HCC cohort. Materials and Methods From 2012 to 2015, 319 newly diagnosed HCC patients were prospectively enrolled at a tertiary hospital. Patient interviews based on a structured questionnaire survey were conducted. Surveillance was defined as liver imaging test ≥ 2 times with at least 3-month interval within 2 years prior to HCC diagnosis. Results Surveillance rate was 39.8%. Of the HCC patients with high-risk factors, only 182 (57.1%) had knowledge for the need for regular surveillance, and 141 (44.2%) had the accurate information about the method (ultrasound-based study). Surveillance group showed a higher proportion of early HCC (p < 0.001) and a longer overall survival (p < 0.001) compared to non-surveillance group. The multivariable Cox regression analysis indicated Child-Pugh class A, history of anti-viral therapy, low serum α-fetoprotein level, non-advanced Barcelona Clinic Liver Cancer stage as independent predictors of overall survival, while regular surveillance was not (p=0.436). Conclusion Less than half of the newly diagnosed Korean HCC patients were under surveillance and the accurate perception for the need of HCC surveillance was insufficient. Of those under surveillance, most patients were diagnosed with early stage HCC, which led to the improved survival. Comprehensive efforts to optimize the surveillance program for the target population are warranted.
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Affiliation(s)
- Sanghyuk Im
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Eun Sun Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ju Hyun Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chung Seop Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Beom Hee Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jung Wha Chung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jin-Wook Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Low Rates of Retention Into Hepatocellular Carcinoma (HCC) Surveillance Program After Initial HCC Screening. J Clin Gastroenterol 2019; 53:65-70. [PMID: 29629906 DOI: 10.1097/mcg.0000000000001024] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
GOALS To evaluate rates and predictors of retention into hepatocellular carcinoma (HCC) surveillance beyond initial screening among underserved cirrhosis patients. BACKGROUND Although initial HCC screening among cirrhosis patients remains low, few studies have evaluated retention to HCC surveillance beyond initial screening. METHODS We retrospectively evaluated all consecutive adults with cirrhosis from 2014 to 2017 at a single underserved safety net hospital system to determine rates of HCC surveillance at 6 months and at 1 year beyond initial screening. Rates of HCC surveillance was stratified by sex, race/ethnicity, and etiology of liver disease. Multivariate Cox proportional hazards models evaluated predictors of retention into HCC surveillance. RESULTS Among 235 cirrhosis patients [hepatitis C virus: 35.7%, hepatitis B virus (HBV): 15.7%, alcoholic cirrhosis: 36.2%, nonalcoholic steatohepatitis (NASH): 8.1%], mean age of cirrhosis diagnosis was 54.2±8.9 years. Overall, 74.8% received initial screening within 1 year of cirrhosis diagnosis. Among those who completed initial screening, 47.6% [95% confidence interval (CI), 41.4-54.2) received second surveillance within 1 year. On multivariate analyses, patients with NASH and HBV were significantly more likely to receive second HCC surveillance compared with hepatitis C virus, HBV (hazard ratio, 2.32; 95% CI, 1.18-4.56; P=0.014) and NASH (hazard ratio, 2.49; 95% CI, 1.22-5.11; P=0.012). No sex or race-specific/ethnicity-specific differences in HCC surveillance retention were observed. CONCLUSIONS Although overall rates of initial HCC screening among cirrhosis patients is nearly 75%, retention into continued HCC surveillance is poor, with less than half of patients undergoing subsequent HCC surveillance. Cirrhosis patients with HBV and NASH were more likely to be retained into HCC surveillance.
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Robinson A, Tavakoli H, Liu B, Bhuket T, Wong RJ. Advanced Hepatocellular Carcinoma Tumor Stage at Diagnosis in the 1945-1965 Birth Cohort Reflects Poor Use of Hepatocellular Carcinoma Screening. Hepatol Commun 2018; 2:1147-1155. [PMID: 30202827 PMCID: PMC6128228 DOI: 10.1002/hep4.1236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/20/2018] [Indexed: 01/20/2023] Open
Abstract
Individuals from the 1945-1965 birth cohort account for the majority of hepatocellular carcinoma (HCC) cases in the United States. Understanding trends in HCC among this birth cohort is vital given the increasing burden of chronic liver disease among this group. We retrospectively evaluated trends and disparities in HCC tumor stage at the time of diagnosis among the 1945-1965 birth cohort in the United States using the Surveillance, Epidemiology, and End Results (SEER) cancer registry. Tumor stage at the time of HCC diagnosis was assessed using Milan criteria and SEER HCC staging systems. Among 38,045 patients with HCC within the 1945-1965 birth cohort (81.6% male, 50.1% non-Hispanic white, 16.2% African American, 12.6% Asian, 19.8% Hispanic), 66.2% had Medicare or commercial insurance, 27.2% had Medicaid, and 6.6% were uninsured. During the period 2004-2006 to 2013-2014, the number of patients with HCC from the 1945-1965 birth cohort increased by 58.7% (5.9% increase per year). While the proportion of patients with HCC within the Milan criteria increased with time (36.4% in 2003-2006 to 46.3% in 2013-2014; P < 0.01), less than half were within the Milan criteria. On multivariate analysis within the Milan criteria, men were 12% less likely to have HCC compared to women, and African Americans were 27% less likely to have HCC compared to non-Hispanic whites (odds ratio, 0.73; 95% confidence interval, 0.68-0.78; P < 0.01). Conclusion: From 2004 to 2014, the burden of newly diagnosed HCC among the 1945-1965 birth cohort increased by 5.9% per year. While improvements in earlier staged HCC at diagnosis were observed, the majority of patients with HCC among the 1945-1965 birth cohort were beyond the Milan criteria at diagnosis; this may reflect poor utilization or suboptimal performance of HCC screening tests.
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Affiliation(s)
- Ann Robinson
- Department of Medicine, Division of Gastroenterology and HepatologyAlameda Health System – Highland HospitalOaklandCA
| | - Hesam Tavakoli
- Department of Medicine, Division of Gastroenterology and HepatologyAlameda Health System – Highland HospitalOaklandCA
| | - Benny Liu
- Department of Medicine, Division of Gastroenterology and HepatologyAlameda Health System – Highland HospitalOaklandCA
| | - Taft Bhuket
- Department of Medicine, Division of Gastroenterology and HepatologyAlameda Health System – Highland HospitalOaklandCA
| | - Robert J. Wong
- Department of Medicine, Division of Gastroenterology and HepatologyAlameda Health System – Highland HospitalOaklandCA
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Medicaid and Uninsured Hepatocellular Carcinoma Patients Have More Advanced Tumor Stage and Are Less Likely to Receive Treatment. J Clin Gastroenterol 2018; 52:437-443. [PMID: 28723861 DOI: 10.1097/mcg.0000000000000859] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOALS To evaluate the impact of insurance status on tumor stage at diagnosis, treatment received, and overall survival among adults with hepatocellular carcinoma (HCC). BACKGROUND Insurance status affects access to care, which impacts timely access to cancer screening for early detection and treatment. STUDY Using the 2007 to 2012 Surveillance, Epidemiology, and End Results (SEER) database, we retrospectively evaluated US adults with HCC. Insurance status included Medicare/commercial insurance (MC), Medicaid (MA), and no insurance (NI). HCC tumor stage was evaluated using SEER staging system and Milan criteria. HCC treatment and survival were evaluated using multivariate logistic regression and Cox proportional hazards models. RESULTS Among 32,388 HCC patients (71.2% MC, 23.9% MA, and 4.9% NI), patients with MA or NI were significantly less likely to have localized tumor stage at time of diagnosis compared with MC [NI vs. MC; odds ratio, 0.41; 95% confidence interval (CI), 0.78-0.92; P<0.001]. MA and NI patients were less likely to receive treatment, and specifically less likely to receive surgical resection or liver transplantation compared with MC patients, even after correcting for tumor stage at diagnosis (odds of surgical resection or liver transplant in NI vs. MC: odds ratio, 0.26; 95% CI, 0.21-0.33; P<0.001). NI patients (hazard ratio, 1.39; 95% CI, 1.29-1.50; P<0.001) had significantly lower survival compared with MC patients. CONCLUSIONS Among US adults with HCC, MA, or NI patients had more advanced tumor stage at diagnosis, lower rates treatment, and significantly lower overall survival. Ensuring equal insurance coverage may improve access to care and mitigate some disparities in HCC outcomes.
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Tran SA, Le A, Zhao C, Hoang J, Yasukawa LA, Weber S, Henry L, Nguyen MH. Rate of hepatocellular carcinoma surveillance remains low for a large, real-life cohort of patients with hepatitis C cirrhosis. BMJ Open Gastroenterol 2018; 5:e000192. [PMID: 29607053 PMCID: PMC5873543 DOI: 10.1136/bmjgast-2017-000192] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/08/2018] [Accepted: 02/16/2018] [Indexed: 01/18/2023] Open
Abstract
Background In patients with chronic hepatitis C (CHC) cirrhosis, imaging for hepatocellular carcinoma (HCC) is recommended every 6 months to maximise eligibility for curative treatment. The aim was to determine the adherence rate and outcomes among patients with CHC cirrhosis and whether the adherence rate has improved over time. Methods Retrospective cohort study of patients with CHC cirrhosis (n=2366) monitored for ≥1 year at Stanford University Medical Center between January 2001 and August 2015. Results Overall demographics: mean age 54; 62.3% men; 48.3% Caucasian. 24.4% adherent to imaging every 6 months per European Association for the Study of the Liver 2000 and American Association for the Study of Liver Diseases (AASLD) 2011 criteria and 44% at least every 12 months per AASLD 2005 criteria. No significant change in adherence before and after 2011. Predictors of multivariable analysis of adherence were age >54 (OR 1.74, p<0.0001), Asian ethnicity (OR 2.23, p<0.0001), liver decompensation (OR 2.40, p<0.0001) and having ≥2 clinical visits per year (OR 1.33, p=0.01). During follow-up, 9.6% were diagnosed with HCC. Adherent patients were more likely to have smaller tumours (2.3 vs 3.3 cm, p=0.0020), be within the Milan criteria for liver transplants (73.2% vs 54.8%, p=0.006) and receive curative HCC treatment (43.6% vs 24.0%, p=0.005). On multivariable analysis, curative treatment (HR 0.32, p=0.001) and every 6-month imaging (HR 0.34, p=0.005), but not every 6–12 month imaging, were associated with reduced risk of mortality. Conclusions Adherence to HCC surveillance continues to be poor. Adherent patients with HCC were more likely to undergo curative treatment and have better survival. Research understanding barriers to surveillance is needed.
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Affiliation(s)
- Sally Ann Tran
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - An Le
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Changqing Zhao
- Department of Cirrhosis, Institute of Liver Disease, Shuguang Hospital, ShangHai, China
| | - Joseph Hoang
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Lee Ann Yasukawa
- Center for Clinical Informatics, Stanford University School of Medicine, Stanford, California, USA
| | - Susan Weber
- Center for Clinical Informatics, Stanford University School of Medicine, Stanford, California, USA
| | - Linda Henry
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
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Provider, Patient, and Practice Factors Shape Hepatitis B Prevention and Management by Primary Care Providers. J Clin Gastroenterol 2017; 51:626-631. [PMID: 27811627 PMCID: PMC5413438 DOI: 10.1097/mcg.0000000000000738] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
GOALS To evaluate provider knowledge, attitudes and barriers to hepatitis B virus (HBV) care and management practices across diverse primary care settings. BACKGROUND Factors influencing adherence to recommended HBV screening and management guidelines are poorly defined. MATERIALS AND METHODS Providers across various health care settings in San Francisco were surveyed. Multivariate analyses were used to identify factors associated with recommended HBV screening, vaccination, and disease monitoring. RESULTS Of 277 (41.3%) responding providers, 42% reported performing HBV screening in >50% of at-risk patients, and 49%, HBV vaccination in >50% of eligible patients. Most reported appropriate monitoring of a majority of HBV-infected patients with alanine aminotransferase (79%) and HBV viral load (67%) every 6 to 12 months, but performed any hepatocellular carcinoma screening in 49%. Provider factors significantly associated with HBV screening were speaking an Asian language [odds ratio (OR), 3.27], offering HBV treatment (OR, 3.00), having >25% of Asian patients in practice (OR, 2.10), practicing in safety net settings (OR, 7.51) and having higher barrier score (OR, 0.74). Appropriate HBV monitoring was associated with provider speaking an Asian language (OR, 3.43) and provider age (OR, 0.68/decade). Hepatocellular carcinoma screening was associated with having >25% of patients speaking English as a second language (OR, 4.26) and practicing in safety net settings (OR, 0.14). CONCLUSIONS Rates of adherence to HBV guidelines were suboptimal irrespective of practice setting and were influenced by certain provider, patient and practice factors. This study reinforces the importance of engaging primary care providers in development, dissemination, and implementation of evidence-based HBV practice guidelines.
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Dang TT, Wong C, Bistritz L. Gastroenterology Curriculum in the Canadian Medical School System. Can J Gastroenterol Hepatol 2017; 2017:8538974. [PMID: 28484687 PMCID: PMC5397633 DOI: 10.1155/2017/8538974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/22/2017] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose. Gastroenterology is a diverse subspecialty that covers a wide array of topics. The preclinical gastroenterology curriculum is often the only formal training that medical students receive prior to becoming residents. There is no Canadian consensus on learning objectives or instructional methods and a general lack of awareness of curriculum at other institutions. This results in variable background knowledge for residents and lack of guidance for course development. Objectives. (1) Elucidate gastroenterology topics being taught at the preclinical level. (2) Determine instructional methods employed to teach gastroenterology content. Results. A curriculum map of gastroenterology topics was constructed from 10 of the medical schools that responded. Topics often not taught included pediatric GI diseases, surgery and trauma, food allergies/intolerances, and obesity. Gastroenterology was taught primarily by gastroenterologists and surgeons. Didactic and small group teaching was the most employed teaching method. Conclusion. This study is the first step in examining the Canadian gastroenterology curriculum at a preclinical level. The data can be used to inform curriculum development so that topics generally lacking are better incorporated in the curriculum. The study can also be used as a guide for further curriculum design and alignment across the country.
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Affiliation(s)
- ThucNhi Tran Dang
- Faculty of Dentistry and Medicine, University of Alberta, Edmonton, AB, Canada
| | - Clarence Wong
- Faculty of Dentistry and Medicine, University of Alberta, Edmonton, AB, Canada
| | - Lana Bistritz
- Faculty of Dentistry and Medicine, University of Alberta, Edmonton, AB, Canada
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Goldberg DS, Taddei TH, Serper M, Mehta R, Dieperink E, Aytaman A, Baytarian M, Fox R, Hunt K, Pedrosa M, Pocha C, Valderrama A, Kaplan DE. Identifying barriers to hepatocellular carcinoma surveillance in a national sample of patients with cirrhosis. Hepatology 2017; 65:864-874. [PMID: 27531119 DOI: 10.1002/hep.28765] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 08/10/2016] [Indexed: 12/11/2022]
Abstract
UNLABELLED Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality in cirrhosis patients. This provides an opportunity to target the highest-risk population, yet surveillance rates in the United States and Europe range from 10% to 40%. The goal of this study was to identify barriers to HCC surveillance, using data from the Veterans Health Administration, the largest provider of liver-related health care in the United States. We included all patients 75 years of age or younger who were diagnosed with cirrhosis from January 1, 2008, until December 31, 2010. The primary outcome was a continuous measure of the percentage of time up-to-date with HCC surveillance (PTUDS) based on abdominal ultrasound (secondary outcomes included computed tomography and magnetic resonance imaging). Among 26,577 patients with cirrhosis (median follow-up = 4.7 years), the mean PTUDS was 17.8 ± 21.5% (ultrasounds) and 23.3 ± 24.1% when any liver imaging modality was included. The strongest predictor of increased PTUDS was the number of visits to a specialist (gastroenterologist/hepatologist and/or infectious diseases) in the first year after cirrhosis diagnosis; the association between visits to a primary care physician and increasing surveillance was very small. Increasing distance to the closest Veterans Administration center was associated with decreased PTUDS. There was an inverse association between ultrasound lead time (difference between the date an ultrasound was ordered and requested exam date) and the odds of it being performed: odds ratio = 0.77, 95% confidence interval 0.72-0.82 when ordered > 180 days ahead of time; odds ratio = 0.90, 95% confidence interval 0.85-0.94 if lead time 91-180 days. CONCLUSIONS The responsibility for suboptimal surveillance rests with patients, providers, and the overall health care system; several measures can be implemented to potentially increase HCC surveillance, including increasing patient-specialist visits and minimizing appointment lead time. (Hepatology 2017;65:864-874).
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Affiliation(s)
- David S Goldberg
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA.,Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | | | - Marina Serper
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Rajni Mehta
- VA Connecticut-Healthcare System, West Haven, CT
| | | | - Ayse Aytaman
- VA New York Harbor Health Care System, Brooklyn, NY
| | | | - Rena Fox
- San Francisco VA Medical Center, San Francisco, CA
| | | | | | | | | | - David E Kaplan
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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Hernaez R, El-Serag HB. Hepatocellular carcinoma surveillance: The road ahead. Hepatology 2017; 65:771-773. [PMID: 27943335 DOI: 10.1002/hep.28983] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/17/2016] [Accepted: 12/06/2016] [Indexed: 12/29/2022]
Affiliation(s)
- Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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Natural History of Untreated Hepatocellular Carcinoma in a US Cohort and the Role of Cancer Surveillance. Clin Gastroenterol Hepatol 2017; 15:273-281.e1. [PMID: 27521507 DOI: 10.1016/j.cgh.2016.07.033] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 07/25/2016] [Accepted: 07/28/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Determining the natural history and predictors of survival in patients with untreated hepatocellular carcinoma (HCC) in the United States is useful to test existing tumor classifications, identify subgroups of patients likely to benefit from treatment, and estimate lead time related to HCC surveillance. METHODS We identified a national cohort of 518 veterans diagnosed with HCC from 2004 through 2011, with follow-up ending in 2014, who received no palliative or curative treatment. We examined the association between postdiagnosis survival and patient factors, tumor characteristics, and prediagnosis surveillance. RESULTS The mean age at HCC diagnosis was 65.7 years and most patients had hepatitis C (60.6%). Almost all patients (99%) died within the observation period; the median overall survival time was 3.6 months and survival times were 13.4, 9.5, 3.4, and 1.6 months for patients of Barcelona Clinic Liver Cancer stages 0/A, B, C, and D, respectively. In addition, model for end-stage liver disease and levels of α-fetoprotein were predictive of survival. Nearly 28% received prediagnosis HCC surveillance, which was associated with detection of disease at an earlier stage (Barcelona Clinic Liver Cancer 0/A/B; 26.4% vs 14.4%; P = .0006) and slightly longer survival than patients with no surveillance overall (5.2 months vs 3.4 months; P = .021); there was no difference in survival times of patients with 0/A stage who did versus did not receive surveillance (10.3 months vs 10.5 months). CONCLUSIONS Patients with HCCs, including those detected through surveillance, survived for short time periods in the absence of treatment, irrespective of their initial stage at diagnosis. Model for end-stage liver disease scores and levels of α-fetoprotein were prognostic factors, independent of Barcelona Clinic Liver Cancer stage. The lead time related to detection by surveillance was modest (<2 months) and therefore unlikely to explain the survival benefit associated with surveillance in previous studies.
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43
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Mikolajczyk AE, Farnan JM, McConville JF, Jensen DM, Reddy KG, Te HS, Reau N, Aronsohn AI. Novel educational interventions in residency increase knowledge of chronic liver disease and career interest in hepatology. Hepatology 2016; 64:2210-2218. [PMID: 27506929 DOI: 10.1002/hep.28741] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 07/05/2016] [Indexed: 01/03/2023]
Abstract
UNLABELLED There is an increasing burden of chronic liver disease (CLD) in the United States but a significant shortage of hepatologists. Thus, it is necessary to develop new recruitment strategies to the field of hepatology as well as ensure that non-gastroenterology-trained physicians are able to capably assist in the care of CLD. We established a novel, nonelective, inpatient hepatology rotation that uses required modules in the American Association for the Study of Liver Diseases Curriculum and Training-First Hepatitis B and C curriculums as well as in LiverLearning. A paper-based anonymous assessment was distributed to the inaugural 25 postgraduate years 2 and 3 internal medicine residents before and after the 2-week rotation over the course of 1 year. Both the prerotation and postrotation assessments included validated multiple-choice questions and Likert-type questions, which evaluated self-perceived knowledge and comfort with managing CLD. The mean comfort level (1 = not at all comfortable/strongly disagree, 5 = very comfortable/strongly agree) of managing several common liver diseases increased significantly after completion of the rotation (i.e., cirrhosis 2.8 versus 3.8, P < 0.001; hepatitis B 2.4 versus 3.4, P = 0.001; hepatitis C 2.6 versus 3.7, P = 0.002; nonalcoholic steatohepatitis 3.0 versus 4.0, P < 0.001; liver transplant care 2.1 versus 3.4, P < 0.001). There was also a significantly increased interest in hepatology as a career (2.6 versus 3.0, P = 0.03). Finally, the mean percentage of multiple-choice questions answered correctly on the pretest was 62% and posttest was 77% (P = 0.02). CONCLUSION Our novel curriculum and nonelective hepatology rotation has effectively demonstrated improvement in internal medicine residents' comfort with and knowledge of CLD, and increased career interest in hepatology was also observed after completion of the curriculum, which suggests that more exposure to CLD could positively impact recruitment to the workforce; larger, multicenter studies are needed to validate these results. (Hepatology 2016;64:2210-2218).
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Affiliation(s)
- Adam E Mikolajczyk
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL
| | - Jeanne M Farnan
- Internal Medicine Residency Program, The University of Chicago Medicine, Chicago, IL
| | - John F McConville
- Internal Medicine Residency Program, The University of Chicago Medicine, Chicago, IL
| | - Donald M Jensen
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL
| | - K Gautham Reddy
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL
| | - Helen S Te
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL
| | - Nancy Reau
- Section of Hepatology, Rush University Medical Center, Chicago, IL
| | - Andrew I Aronsohn
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, IL
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44
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Sclair SN, Carrasquillo O, Czul F, Trivella JP, Li H, Jeffers L, Martin P. Quality of Care Provided by Hepatologists to Patients with Cirrhosis at Three Parallel Health Systems. Dig Dis Sci 2016; 61:2857-2867. [PMID: 27289585 DOI: 10.1007/s10620-016-4221-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/29/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Evidence-based guidelines and quality indicators for cirrhosis care have been established. Whether there are variations in adherence to these cirrhosis standards at different specialty settings has not been investigated. AIMS To evaluate the quality of cirrhosis care delivered at diverse hepatology care sites. METHODS We conducted a retrospective study comparing the quality of care at three hepatology specialty clinics: a Faculty Practice, safety-net hospital, and Veterans Affairs (VA) Medical Center. Consecutive patients with cirrhosis (85 Faculty Practice, 81 safety-net, and 76 VA) between 2010 and 2011 were included. Median follow-up was 2.3 years. Outcome measures were the adherence to six cirrhosis-specific quality-of-care indicators. RESULTS Adherence to hepatitis A and B vaccinations was highest at the safety-net hospital, 81 and 74 %, compared to 46 and 30 % at the Faculty Practice (P < .001). Adherence to yearly hepatocellular carcinoma surveillance was highest at the safety-net site (79 %) versus the VA (50 %) and Faculty Practice (42 %), P = .001. In contrast, screening rates for esophageal varices were 75 % at the Faculty Practice and only 58 and 43 % at the VA and safety-net sites, respectively (P < .001). Liver transplant discussions were documented most consistently at the Faculty Practice (82 %) compared to the safety-net site (53 %) and VA (54 %), P < .001. CONCLUSIONS Disparities in cirrhosis quality measures existed by site. Strategies to overcome these disparities need to be developed to improve the delivery of quality cirrhosis care as we face a rise in cirrhosis-related complications over the next two decades.
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Affiliation(s)
- Seth N Sclair
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Olveen Carrasquillo
- Division of General Internal Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Miami Clinical and Translational Sciences Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Frank Czul
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan P Trivella
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hua Li
- Miami Clinical and Translational Sciences Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Biostatistics Collaboration and Consulting Core, Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Lennox Jeffers
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Hepatology Section, Medicine Service, Miami VA Medical Center, Miami, FL, USA
| | - Paul Martin
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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Bird TG, Dimitropoulou P, Turner RM, Jenks SJ, Cusack P, Hey S, Blunsum A, Kelly S, Sturgeon C, Hayes PC, Bird SM. Alpha-Fetoprotein Detection of Hepatocellular Carcinoma Leads to a Standardized Analysis of Dynamic AFP to Improve Screening Based Detection. PLoS One 2016; 11:e0156801. [PMID: 27308823 PMCID: PMC4911090 DOI: 10.1371/journal.pone.0156801] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 05/19/2016] [Indexed: 02/06/2023] Open
Abstract
Detection of hepatocellular carcinoma (HCC) through screening can improve outcomes. However, HCC surveillance remains costly, cumbersome and suboptimal. We tested whether and how serum Alpha-Fetoprotein (AFP) should be used in HCC surveillance. Record linkage, dedicated pathways for management and AFP data-storage identified i) consecutive highly characterised cases of HCC diagnosed in 2009–14 and ii) a cohort of ongoing HCC-free patients undergoing regular HCC surveillance from 2009. These two well-defined Scottish patient cohorts enabled us to test the utility of AFP surveillance. Of 304 cases of HCC diagnosed over 6 years, 42% (129) were identified by a dedicated HCC surveillance programme. Of these 129, 47% (61) had a detectable lesion first identified by screening ultrasound (US) but 38% (49) were prompted by elevated AFP. Despite pre-HCC diagnosis AFP >20kU/L being associated with poor outcome, ‘AFP-detected’ tumours were offered potentially curative management as frequently as ‘US-detected’ HCCs; and had comparable survival. Linearity of serial log10-transformed AFPs in HCC cases and in the screening ‘HCC-free’ cohort (n = 1509) provided indicators of high-risk AFP behaviour in HCC cases. An algorithm was devised in static mode, then tested dynamically. A case/control series in hepatitis C related disease demonstrated highly significant detection (p<1.72*10−5) of patients at high risk of developing HCC. These data support the use of AFP in HCC surveillance. We show proof-of-principle that an automated and further refine-able algorithmic interpretation of AFP can identify patients at higher risk of HCC. This approach could provide a cost-effective, user-friendly and much needed addition to US surveillance.
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Affiliation(s)
- Thomas G Bird
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom.,Cancer Research UK Beatson Institute, Glasgow, G61 1BD, United Kingdom
| | | | | | - Sara J Jenks
- Department of Clinical Biochemistry, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Pearce Cusack
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Shiying Hey
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Andrew Blunsum
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Sarah Kelly
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Catharine Sturgeon
- Department of Clinical Biochemistry, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Peter C Hayes
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Sheila M Bird
- MRC Biostatistics Unit, Cambridge, CB2 0SR, United Kingdom.,Department of Mathematics and Statistics, Strathclyde University, Glasgow, G1 1XH, United Kingdom
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46
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Walker M, El-Serag HB, Sada Y, Mittal S, Ying J, Duan Z, Richardson P, Davila JA, Kanwal F. Cirrhosis is under-recognised in patients subsequently diagnosed with hepatocellular cancer. Aliment Pharmacol Ther 2016; 43:621-30. [PMID: 26784271 PMCID: PMC4742403 DOI: 10.1111/apt.13505] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 05/03/2015] [Accepted: 11/30/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Most clinical practice guidelines recommend screening for HCC in patients with cirrhosis. However, patients with compensated cirrhosis are often asymptomatic and may remain unrecognised for years. AIMS To determine the extent to which cirrhosis is unrecognised in a US Veteran population with HCC, and to evaluate the association between lack of cirrhosis recognition and stage of HCC at diagnosis. METHODS We reviewed the electronic medical records of a random sample of HCC cases diagnosed in the national Veterans Affairs system between 2005 and 2011. We conducted multivariable analyses adjusting for patients' demographics, comorbidity, aetiology of underlying disease and healthcare utilisation including HCC surveillance. RESULTS Of 1201 patients with HCC and cirrhosis, 24.6% had unrecognised cirrhosis prior to HCC diagnosis. Older patients [>65 years, odds ratio (OR) 2.32], African Americans (OR 1.93), patients with alcoholic or NAFLD liver disease (OR 1.69 and 4.77 respectively), HIV (OR 3.02), and fewer comorbidities (Deyo 0 vs. 3, OR 2.42) had significantly higher odds of having unrecognised cirrhosis than comparison groups. Furthermore, patients with unrecognised cirrhosis were 6.5 times more likely to have advanced stage HCC at diagnosis. The effect of cirrhosis recognition on HCC stage remained significant after adjusting for pre-specified covariates (OR 3.37). CONCLUSIONS In one quarter of patients, cirrhosis was unrecognised prior to HCC diagnosis, and this group was significantly more likely to have advanced stage HCC. These findings emphasise the importance of timely evaluation for cirrhosis in at-risk populations as a critical step to improving outcomes for patients with HCC.
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Affiliation(s)
- M Walker
- Department of Medicine, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - H B El-Serag
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Sections of Gastroenterology and Hepatology, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Y Sada
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Hematology and Oncology, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - S Mittal
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Sections of Gastroenterology and Hepatology, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - J Ying
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Z Duan
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - P Richardson
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - J A Davila
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - F Kanwal
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Sections of Gastroenterology and Hepatology, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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Abstract
Hepatocellular carcinoma (HCC) is the seventh most common malignancy worldwide. HCC meets all the criteria established by the World Health Organization for performing surveillance on those at-risk for developing cancer. Although there are consensus guidelines in the United States, Europe, and Asia for HCC surveillance, it is unclear if these guidelines are regularly implemented in routine practice to optimize real-life clinical outcomes. We reviewed the current literature on the adherence to current HCC practice guidelines by the American Association for the Study of Liver Diseases (2009), the European Association for the Study of the Liver (2012), and the Asia Pacific Association for the Study of the Liver (2010) for screening/surveillance and outcomes of optimal versus poor adherence. We performed PubMed search for relevant articles regarding HCC surveillance and screening worldwide. Currently, HCC screening is underutilized to a large extent. In most studies, the adherence to HCC screening and surveillance is suboptimal. Various patient, provider, and health care system factors may have all contributed to such nonadherence. Strategies to improve HCC screening and surveillance are urgently needed for early HCC detection and improved survival of HCC patients. Further research is needed to elucidate the various medical and/or cultural knowledge, belief, and practice patterns that can lead to barriers to HCC screening and surveillance at both patient and provider levels. These data will help focus and target advocacy and educational efforts to improve HCC surveillance at all levels: patients, providers, and health care system/government.
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48
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Singal AG, El-Serag HB. Hepatocellular Carcinoma From Epidemiology to Prevention: Translating Knowledge into Practice. Clin Gastroenterol Hepatol 2015; 13:2140-51. [PMID: 26284591 PMCID: PMC4618036 DOI: 10.1016/j.cgh.2015.08.014] [Citation(s) in RCA: 401] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/11/2015] [Accepted: 08/11/2015] [Indexed: 02/07/2023]
Abstract
The epidemiology of hepatocellular carcinoma (HCC) is characterized by dynamic temporal trends, several major established (i.e., HCV, HBV, alcohol) and emerging (i.e., diabetes, obesity, NAFLD) risk factors. Epidemiologic studies and clinical trials have identified additional demographic, clinical, pharmacological, genetic and life style factors that further affect or modify the likelihood of HCC and can be used in clinical practice to identify at-risk patients (i.e., risk stratification or prognostic algorithms) that can be targeted for prevention and early detection programs. These studies have also paved the way toward several well established preventive measures including HBV vaccination, HBV treatment, HCV treatment and HCC surveillance, and potential chemoprevention using statins, metformin or coffee. However, the effectiveness of HCC prevention in clinical practice and at the population level has lagged behind due to patient, provider, system, and societal factors. The Quality in the Continuum of Cancer Care model provides a framework for evaluating the HCC prevention processes, including potential failures that create a gap between efficacy and effectiveness.
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Affiliation(s)
- Amit G Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology and Center (Center for Innovations in Quality, Effectiveness and Safety), Michael E DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas.
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49
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Vilarinho S, Taddei T. Therapeutic strategies for hepatocellular carcinoma: new advances and challenges. ACTA ACUST UNITED AC 2015; 13:219-34. [PMID: 25791207 DOI: 10.1007/s11938-015-0049-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OPINION STATEMENT Hepatocellular carcinoma (HCC) is the fastest growing malignancy in the USA, and its prognosis remains poor with a 5-year survival around 12 %. Clinical data demonstrate that 85 % of cases occur in individuals with underlying cirrhosis and only 15 % develop in non-cirrhotic livers. Therefore, American and European guidelines recommend routine HCC screening for high-risk individuals (patients with cirrhosis) with abdominal ultrasound every 6 months. Once a lesion is identified or suspected on ultrasound, dynamic imaging is then indicated. The diagnosis of HCC is established in a patient with cirrhosis when a lesion measures at least 1 cm in diameter and demonstrates arterial enhancement and portal venous washout on contrast-enhanced computerized tomography or magnetic resonance imaging. Indeterminate lesions should be followed with surveillance imaging or further investigated with biopsy according to the level of suspicion for malignancy. Given the clinical, pathological, and molecular heterogeneity of HCC, there are multiple therapeutic modalities available. These may be curative, such as surgical resection, liver transplantation, and local ablation, or palliative, such as catheter-directed therapies (transarterial chemo, radio, or bland embolization), and systemic therapy (sorafenib). Patients with a single lesion, good performance status, and preserved liver synthetic function should be offered curative surgical resection or ablation therapy. Patients with HCC and decompensated liver disease should be evaluated and listed for liver transplantation. For unresectable disease or tumor burden precluding transplantation or curative ablation, palliative therapeutic modalities should be offered. Sorafenib is indicated for patients with vascular invasion and/or extra-hepatic metastasis if the estimated life expectancy is more than 3 months. Systemic internal radiation therapy using yttrium-90 microspheres in cases of multifocal bi-lobar disease and/or portal vein occlusion is an emerging therapy. Best supportive care is recommended for patients who lack the hepatic reserve to tolerate therapy.
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Affiliation(s)
- Sílvia Vilarinho
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, CT, 06520-8019, USA,
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50
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Kanwal F, El-Serag HB, Ross D. Surveillance for hepatocellular carcinoma: can we focus on the mission? Clin Gastroenterol Hepatol 2015; 13:805-7. [PMID: 25541193 DOI: 10.1016/j.cgh.2014.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 12/11/2014] [Accepted: 12/12/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Fasiha Kanwal
- Michael E. DeBakey VA and Baylor College of Medicine, Houston, Texas
| | - Hashem B El-Serag
- Michael E. DeBakey VA and Baylor College of Medicine, Houston, Texas
| | - David Ross
- Veterans Health Administration Office of Public Health, Washington DC VA Medical Center, and George Washington University School of Medicine and Health Sciences, Washington, DC
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