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Cirrhosis-related financial burden impairs liver cancer surveillance

BOSTON — Researchers found that health care financial burden was common in patients with cirrhosis and may be associated with lower receipt of hepatocellular carcinoma surveillance, according to a presenter at The Liver Meeting 2019.

“The impetus of our study was prior data that suggested patients with cancer often report medical-related financial problems including high out-of-pocket cost, medical debt, and even bankruptcy,” Amit G. Singal, MD, MS, from the University of Texas Southwestern Medical Center, said during a press conference. “While this has been described in patients with cancer, there is less data on the impact in cirrhosis.”

Singal and colleagues conducted a telephone-based survey study among patients with cirrhosis at three U.S. health systems including a tertiary care referral center, safety-net health system, and a Veterans Association hospital between April and December 2018.

They assessed surveillance measures and barriers along with HCC surveillance by abdominal ultrasound in the year prior to the survey.

Most of the 1,021 patients who responded did receive surveillance in the prior year (64%). However, they reported worry about developing HCC, including 74.1% who reported they were at least somewhat likely to develop HCC during their lifetime and 36.9% who expressed a fear of dying from HCC.

While 89% reported that HCC surveillance was “very important,” patients also reported barriers to receiving surveillance including cost of testing (28.9%), difficulty with the scheduling process (24.1%), uncertainty regarding where to complete an ultrasound (17.1%), and transportation difficulties (17.8%).

Most reported active insurance (91.8%), but financial burden of medical care including the cost of HCC surveillance resulted in delayed care (9.5%), needing to borrow money to avoid debt (11.8%), inability to cover copayments and deductibles (24.4%), and worry about the ability to pay medical bills (42.8%).

Receipt of surveillance correlated with the presence of documented cirrhosis (P = .04), the number of primary care visits (P < .001), and receipt of hepatology care (P < .001). Additionally, lack of insurance (OR 0.53; 95% CI, 0.33-0.86) and financial distress resulting in delayed medical care (OR 0.73; 95% CI 0.54-0.98) were both associated with lower odds of HCC surveillance receipt.

Singal noted that there was no difference in surveillance receipt by patient fear of developing HCC or perceived importance of surveillance, but lack of insurance and financial distress correlated with delayed medical care and lower odds for HCC surveillance receipt.

“Our results have significant implications for what we need to do as next steps in terms of improving the receipt of HCC screening in this high-risk patient population. The first is that we think this informs immediate interventions that focus on patient navigation, including possible interventions to reduce out-of-pocket costs for our patients. Most importantly in the long term, we need to focus on policy reform that will expand medical coverage for these patients, reduce costs, and improve overall care.” – by Talitha Bennett

Reference: Singal AG. Abstract 0201. Presented at: The Liver Meeting; Nov. 7-12, 2019; Boston.

Disclosure: Singal reports he is on an advisory committee or review panel with TARGET and consults for Bayer, Bristol-Myers Squibb, Eisai, Exact Sciences, Exelixis, Glycotest and Roche.