Diagnostic and Therapeutic Delays in Patients With Hepatocellular Carcinoma

Abstract

Background: Delays in diagnosis and treatment have been reported for many cancers, with resultant stage migration and worse survival; however, few data exist in patients with hepatocellular carcinoma (HCC). These data are of particular importance in light of the COVID-19 pandemic, which has caused disruptions in healthcare processes and may continue to impact cancer care for the foreseeable future. The aim of our study was to characterize the prevalence and clinical significance of diagnostic and treatment delays in patients with HCC. Methods: We performed a retrospective cohort study of consecutive patients diagnosed with HCC between January 2008 and July 2017 at 2 US health systems. Diagnostic and treatment delays were defined as >90 days between presentation and HCC diagnosis and between diagnosis and treatment, respectively. We used multivariable logistic regression to identify factors associated with diagnostic and treatment delays and Cox proportional hazard models to identify correlates of overall survival. Results: Of 925 patients with HCC, 39.0% were diagnosed via screening, 33.1% incidentally, and 27.9% symptomatically. Median time from presentation to diagnosis was 37 days (interquartile range, 18–94 days), with 120 patients (13.0%) experiencing diagnostic delays. Median time from HCC diagnosis to treatment was 46 days (interquartile range, 29–74 days), with 17.2% of patients experiencing treatment delays. Most (72.5%) diagnostic delays were related to provider-level factors (eg, monitoring indeterminate nodules), whereas nearly half (46.2%) of treatment delays were related to patient-related factors (eg, missed appointments). In multivariable analyses, treatment delays were not associated with increased mortality (hazard ratio, 0.90; 95% CI, 0.60–1.35); these results were consistent across subgroup analyses by Barcelona Clinic Liver Cancer stage and treatment modality. Conclusions: Diagnostic and therapeutic delays exceeding 3 months are common in patients with HCC; however, observed treatment delays do not seem to significantly impact overall survival.

Therapeutic Underuse and Delay in Hepatocellular Carcinoma: Prevalence, Associated Factors, and Clinical Impact

“…(30) Subsequent retrospective cohort studies from an urban safety-net hospital and the Department of Veterans Affairs both reported approximately onethird of patients with HCC failed to receive cancer treatment. (9,30,31) In our study, we found this to be true in a smaller proportion of patients, consistent with observed trends, suggesting increased treatment use over time. The improved treatment use may reflect increasing treatment options with higher efficacy, particularly for those with advanced-stage HCC.…”

“…Treatment delay was defined as time from diagnosis to treatment exceeding 90 days based on HCC doubling time and as used in prior publications. (9,21,25) Institutional review board review was exempted as the study involved the analysis of the de-identified data set.…”

Racial, Ethnic, and Socioeconomic Disparities in Curative Treatment Receipt and Survival in Hepatocellular Carcinoma

“…( 32 , 33 ) Several studies have suggested lower HCC surveillance receipt in racial–ethnic minorities and more advanced tumor burden at diagnosis. ( 13 , 24 , 28 , 30 ) Although recent data suggest variation in tumor growth patterns, there are no ethnic disparities in the frequency of common somatic mutations associated with HCC (e.g., catenin beta 1 [ CTNNB1 ]) and no convincing data demonstrating racial and ethnic disparities in tumor biology and growth patterns. ( 32 , 33 ) Compared to other racial–ethnic groups, Asians are more likely to have underlying HBV infection, which can cause HCC in the absence of cirrhosis and may facilitate curative surgical resection.…”

“…Patients living in high-poverty neighborhoods may also have other noninsurance-related barriers that can result in missed visits and postponed care or shortages of physicians and subspecialists in medically underserved areas. (27)(28)(29)(30) In particular, the availability of liver transplantation and hepatic resection may be limited in these areas. (31) Differential access to health care may not wholly explain racial and ethnic disparities in prognosis and subsequent receipt of curative treatment.…”

Development and Validation of a Prediction Model for Predicting the Prognosis of Postoperative Patients with Hepatocellular Carcinoma

“…In recent years, studies have focused on expanding the indications for surgical resection of HCC in the high-incidence areas of Asia, and it has been proven that surgical resection can improve the survival rate more than other palliative treatments. 11 Some studies have found that surgery to treat HCC patients in the middle and late stages has the same effect as TACE. 12 According to the 2020 European Society for Medical Oncology (ESMO) guidelines, sorafenib, lenvatinib, and a combination of atezolizumab plus bevacizumab are three different First-line therapeutic options.…”