Barriers to Surveillance for Hepatocellular Carcinoma in a Multicenter Cohort

Abstract

IMPORTANCEHepatocellular carcinoma (HCC) surveillance is underused in clinical practice, which may be owing to patient and clinician barriers. OBJECTIVE To characterize HCC surveillance barriers and associations with clinical outcomes in a multicenter cohort of patients with cirrhosis. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included 5 medical centers in the United States. Patients with cirrhosis and newly diagnosed HCC treated from 2014 to 2018 were included. Data were analyzed from June 2021 to February 2022. EXPOSURE Surveillance completion in the 36-month period prior to HCC diagnosis. MAIN OUTCOMES AND MEASURES Surveillance receipt was classified as semiannual, annual, or no surveillance. Multivariable logistic regression analysis was used to identify factors associated with semiannual surveillance. We conducted multivariable logistic and Cox regression analyses to characterize associations between surveillance completion with curative treatment and overall survival. RESULTS A total 629 eligible patients (median [IQR] age, 63.6 [56.2-71.0] years; 491 [78.1%] men) were assessed, including 7 American Indian or Alaska Native patients (1.1%), 14 Asian patients (2.2), 176 Black patients (28.0%), 86 Hispanic patients (13.1%), and 340 White patients (54.1%). Nearly two-thirds of the cohort had no surveillance prior to HCC diagnosis (mean [range by site] 63.7%[37.9%-80.4%]), with a mean (range by site) of 14.0% (5.3%-33.3%) of patients having received semiannual surveillance and 22.3% (14.3%-28.8%) of patients having received annual surveillance.The most common reasons for no surveillance were lack of surveillance orders or nonadherence (mean [range by site], 82.4% [66.7%-92.4%], although a mean (range by site) of 17.6% (10.2%-22.1%) of patients had unrecognized cirrhosis at HCC presentation. Semiannual surveillance was associated with hepatitis B infection (odds ratio [OR], 3.06 [95% CI, 1.24-7.23]) and inversely associated with Black race (OR, 0.41 [95% CI, 0.20-0.80]) and lack of cirrhosis recognition (OR, 0.14 [95% CI, 0.02-0.46]). Semiannual HCC surveillance was significantly associated with curative treatment receipt (OR, 2.73 [95% CI, 1.60-4.70]) but not overall survival (HR, 0.81 [95% CI, 0.55-1.18]). CONCLUSIONS AND RELEVANCEIn this cohort study of patients with cirrhosis, HCC surveillance was underused in more than 80% of patients and associated with failures across the screening process. Dedicated programs to improve cirrhosis detection and HCC surveillance attainment are needed.

Physician- and patient-reported barriers to hepatocellular carcinoma surveillance: A nationwide survey

“…This was supported by the finding from a previous study reporting that physicians' knowledge deficit regarding the clinical indications may indicate as a reason for the lack of US prescription. [9] This observation was consistently reported in several studies, [9][10][11][12][13] suggesting that physician knowledge of HCC screening guidelines was the most important factor to proper HCC surveillance. Regarding the physicians' attitude toward HCC surveillance, most physicians believed that the surveillance was a responsibility shared by all healthcare providers regardless of medical specialty and hospital limitations.…”

Hepatocellular carcinoma surveillance in patients with non-alcoholic fatty liver disease

“…(7) There are many patient-and provider-level barriers to HCC surveillance, contributing to HCC surveillance underuse. (77)(78)(79) Provider-level barriers to surveillance include time constraints in clinic, inadequate knowledge about guidelines, and difficulty identifying at-risk patients. (80) As discussed above, identification of at-risk patients with NAFLD can be particularly problematic for providers.…”

Epidemiology of liver cirrhosis and associated complications: Current knowledge and future directions

“…In a United States nationwide cohort of patients with cirrhosis, only 8.78% of patients were under surveillance for HCC[ 142 ]. A retrospective multicenter cohort study found that the main reason for barriers to surveillance was lack of surveillance orders or nonadherence[ 143 ]. Another United States survey identified patient-reported barriers to surveillance as knowledge deficits about HCC surveillance, cost, difficulty scheduling and transportation[ 144 ].…”