Patterns of Consultation and Treatment of Patients with Hepatocellular Carcinoma Presenting to a Large Academic Medical Center in the US

Abstract

Background Management of hepatocellular carcinoma (HCC) often involves many subspecialist providers, as well as a broad range of treatment options. This study sought to evaluate referral and treatment patterns among patients with HCC at a large academic medical center. Methods Data from our cancer registry between 2003–2011 were abstracted on 394 patients who were primarily diagnosed/treated for HCC at Johns Hopkins Hospital (JHH); data on patients who were diagnosed/treated with HCC elsewhere and who received secondary treatment at JHH (n=391) were also abstracted for comparison purposes. Results Among the main cohort, the most common specialties to be consulted were surgery (n=225, 57.1 %), gastroenterology (n=225, 57.1 %), and interventional radiologist (n=206, 52.3 %), while only 96 (24.4 %) were referred to medical oncology. Factors associated with surgical consultation included younger age (odds ratio (OR) 3.35, 95 % CI 1.62–6.92), tumor size <5 cm (OR 1.82, 1.09–3.02), and unilobar disease (OR 2.94, 1.31–6.59) (all P<0.05). Patients initially diagnosed/treated elsewhere had larger tumors (4 vs. 6 cm), bilateral disease (19.2 vs. 26.8 %), and were more likely to be seen by interventional radiology (all P<0.05) Conclusions Most patients were seen by surgeons, gastroenterologists, or interventional radiologists, with only a minority being seen by medical oncologists. Referral patterns depended on patient-level factors, as well as extent of disease.

Temporal trends in population‐based death rates associated with chronic liver disease and liver cancer in the United States over the last 30 years

“…Furthermore, our group has documented variation in choice of therapy for patients with liver cancer and has demonstrated that receipt of therapy depends on a wide variety of factors, including clinical data as well as provider‐level and hospital‐level factors . In fact, even referral to a specialist varies considerably, with barriers to treatment preventing up to 50% of patients who have early stage disease from receiving potentially curative therapy …”

Impact of the Treating Hospital on Care Outcomes for Hepatocellular Carcinoma

“…Also, considerable variation in referral patterns, time to referral, and specific consultation teams exists across the country . Even within a single large academic institution, Stacy et al found no uniform pattern of referral for evaluation and treatment of patients newly diagnosed with HCC . Patient‐level factors impacting timeliness of referral as well as access to potentially curative therapy for HCC include age, disease stage, geographic area, and the underlying causes of cirrhosis—patients with ongoing substance abuse are not candidates for OLT and therefore may not be referred for evaluation at Type IV centers .…”

“…(15) Even within a single large academic institution, Stacy et al found no uniform pattern of referral for evaluation and treatment of patients newly diagnosed with HCC. (16) Patient-level factors impacting timeliness of referral as well as access to potentially curative therapy for HCC include age, disease stage, geographic area, and the underlying causes of cirrhosis-patients with ongoing substance abuse are not candidates for OLT and therefore may not be referred for evaluation at Type IV centers. (15,16) Other factors including insurance coverage, social support networks, race, and ethnicity also impact both the type of hospital in which patients are treated and the outcome following HCC diagnosis.…”

“…(16) Patient-level factors impacting timeliness of referral as well as access to potentially curative therapy for HCC include age, disease stage, geographic area, and the underlying causes of cirrhosis-patients with ongoing substance abuse are not candidates for OLT and therefore may not be referred for evaluation at Type IV centers. (15,16) Other factors including insurance coverage, social support networks, race, and ethnicity also impact both the type of hospital in which patients are treated and the outcome following HCC diagnosis. (17)(18)(19) An important finding is the dose-response relationship between an increasing complement of interventional services offered by the treating hospital and improved patient outcomes across all therapeutic modalities and stages of disease.…”

Multidisciplinary decision making in the management of hepatocellular carcinoma: A hospital-based study

“…As such, the manage- Table 5. Changes in the laboratory data of the study group before and after interventions Original Article ment of HCC often involves many subspecialist providers (8). HCC patients require MDT management to select treatments according to tumor stage, performance status, and hepatic function (9).…”