HCC surveillance underused in most patients with cirrhosis; screening improvements needed
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Hepatocellular carcinoma surveillance was underutilized in more than 80% of patients with cirrhosis, with lack of clinician orders and lack of patient adherence cited as common screening barriers, according to a study in JAMA Network Open.
“We found that screening attainment with semiannual, or even annual, ultrasound was low,” Neehar D. Parikh, MD, MS, study co-author and assistant professor of gastroenterology and hepatology at the University of Michigan, Ann Arbor, told Healio. “We found common barriers included lack of screening order, lack of patient follow-up for screening and nearly 18% of patients had unrecognized cirrhosis prior to HCC diagnosis.”
To characterize barriers to HCC surveillance, Parikh and colleagues retrospectively reviewed data for 629 patients with cirrhosis and newly diagnosed HCC at five U.S. medical centers, including three tertiary care referral centers, a safety-net center and a Veterans Health Administration hospital. HCC status was identified using ICD-9 and ICD-10 codes and tumor board presentation lists, and diagnoses were confirmed using American Association of Liver Disease criteria. Investigators assessed HCC surveillance at primary care or hepatology clinics 12 to 36 months before HCC diagnosis.
The median age of the patient cohort was 63.6 years and 78.1% were men. The group included 54.1% white patients, 28% Black patients and 13.1% Hispanic patients.
Researchers reported 63.7% of patients had no surveillance prior to HCC diagnosis, 22.3% underwent annual surveillance and 14% had semiannual surveillance. Lack of surveillance orders or patient nonadherence were cited as reasons for not having surveillance in 82.4% of cases, while 17.6% had undiagnosed cirrhosis at HCC presentation.
In addition, semiannual surveillance was linked with hepatitis B infection (OR = 3.06; 95% CI, 1.24-7.23) and inversely linked with Black race (OR = 0.41; 95% CI, 0.2-0.8) and unrecognized cirrhosis (OR = 0.14; 95% CI, 0.02-0.46).
Although semiannual surveillance was significantly associated with curative treatment (OR = 2.73; 95% CI, 1.6-4.7), it was not linked with overall survival (HR = 0.81; 95% CI, 0.55-1.18).
“The most surprising finding was that screening was not associated with early detection or overall survival but was associated with curative treatment receipt,” Parikh said. “These patients were, by definition, followed with regular medical care and a high proportion (75.4%) of patients were found to have their HCC on a screening test, even though many did not have regular annual or semiannual screening prior to their diagnosis of HCC.”
Further, researchers wrote that they observed “significant site-level variation in surveillance attainment, highlighting particular opportunities to target interventions at low-performing sites or patients at high risk of surveillance failure.”
“The study speaks to the need to improve screening programs for hepatocellular carcinoma by targeting ordering, patient completion of screening tests and improving recognition of cirrhosis,” Parikh said.
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