Referral and receipt of treatment for hepatocellular carcinoma in United States veterans: Effect of patient and nonpatient factors

Abstract

Background The delivery of treatment for hepatocellular carcinoma (HCC) could be influenced by place of HCC diagnosis (hospitalization vs. outpatient), subspecialty referral following diagnosis, as well as physician and facility factors. We conducted a study to examine the effect of patient and non-patient factors on the place of HCC diagnosis, referral, and treatment in Veterans Administration (VA) hospitals in the United States. Methods Using the VA Hepatitis C Clinical Case Registry, we identified HCV-infected patients who developed HCC during 1998–2006. All cases were verified and staged according to Barcelona Clinic Liver Cancer (BCLC) criteria. The main outcomes were place of HCC diagnosis, being seen by a surgeon or oncologist, and treatment. We examined factors related to these outcomes using hierarchical logistic regression. These factors included HCC stage, HCC surveillance, physician specialty, and facility factors, in addition to risk factors, co-morbidity, and liver disease indicators. Results Approximately 37.2% of the 1,296 patients with HCC were diagnosed during hospitalization, 31.0% were seen by a surgeon or oncologist, and 34.3% received treatment. Being seen by a surgeon or oncologist was associated with surveillance (adjusted odds ratio (aOR)=1.47;95%CI:1.20–1.80) and varied by geography (1.74;1.09–2.77). Seeing a surgeon or oncologist was predictive of treatment (aOR=1.43;95%CI:1.24–1.66). There was a significant increase in treatment among patients who received surveillance (aOR=1.37; 95%CI:1.02–1.71), were seen by gastroenterology (1.65;1.21–2.24) or were diagnosed at a transplant facility (1.48;1.15–1.90). Conclusions Approximately 40% of patients were diagnosed during hospitalization. Most patients were not seen by a surgeon or oncologist for treatment evaluation and only 34% received treatment. Only receipt of HCC surveillance was associated with increased likelihood of outpatient diagnosis, being seen by a surgeon or oncologist, and treatment.

Establishment of a Regional Virtual Tumor Board Program to Improve the Process of Care for Patients With Hepatocellular Carcinoma

“…1,21 Despite being endorsed as a critical model in the management of HCC, 4,8 multidisciplinary-based care is rarely accomplished during the process of care for HCC. 6,7 Telemedicine applications, such as the VTB program described in this study, can increase access to comprehensive MDE at institutions lacking the necessary workforce and/or infrastructure to appropriately evaluate patients with complex cancers. The findings from this study are significant, because it specifically examined the impact of a regional VTB program on the MDE process for patients with HCC within an integrated health care system.…”

“…A retrospective cohort study using the VA Hepatitis C Clinical Case Registry in 2013 reported that only 31% of patients with HCC were evaluated by a surgeon or oncologist 7 ; another analysis using the SEER-Medicare database over a similar time period revealed that only 39% of patients with HCC were evaluated by Ն three HCC cancer care specialists. 6 The perfect guideline-driven MDE rate observed in patients evaluated through the VTB program reported in this study is the result of the establishment of a guideline-based process as part of the VTB implementation process, grounded on a validated framework for TB implementation, which minimizes program barriers, 23,24 and is congruent with the high provider acceptance (satisfaction and confidence) and use rates associated with the program, which we previously reported.…”

“…[1][2][3] The prognosis for HCC is determined by the interaction between tumor-related factors and underlying liver disease [4][5][6] ; treatment for HCC is therefore complex, with competing factors often precluding the ability to provide the best treatment and significant variability in outcomes resulting from inefficient health care delivery and substandard care. 7 Evidence-based guidelines recommend the use of a multidisciplinary approach, with a minimum set of specialists, as the standard of care. Tumor boards (TBs) have emerged as a multidisciplinary forum targeted at providing this standard 4,8 and have been shown to be associated with improved satisfaction, outcome, and survival of patients with HCC.…”

Surveillance for early diagnosis of hepatocellular carcinoma: How best to do it?

“…Some recent studies, coming from the United States, have helped frame the receipt of HCC surveillance in everyday practice in this country and reported the obstacles to its utilization, providing hints on how to improve its uptake and outcome [116][117][118][119][120][121] . Indeed, initial reports showed that no more than 28% of patients diagnosed with HCC underwent at least 1 screening test in the 3 years preceding the diagnosis and, among them, 36% received AFP testing alone as a screening test [117] .…”

Management of Hepatocellular Carcinoma: An Update at the Start of 2014

“…In Japan hepatitis C virus [HCV]-related HCC represents 70% of all cases [2]. In addition, in the USA and Europe, an increased incidence of HCV has led to an increased incidence of HCC [3]. A relevant risk factor for the high incidence of nonalcoholic fatty liver disease is obesity and diabetes, which can promote the development of liver cancer [4].…”