Hepatocellular Carcinoma Screening Process Failures in Patients with Cirrhosis

Abstract

Professional society guidelines recommend semiannual screening for hepatocellular carcinoma (HCC) in patients with cirrhosis; however, studies suggest underuse of screening in clinical practice. Our study's aim was to characterize reasons for HCC screening underuse among patients with cirrhosis. We conducted a retrospective cohort study of patients with cirrhosis diagnosed with HCC in two large health systems from 2011 to 2019. We classified screening receipt as consistent, inconsistent, or no screening in the year before HCC diagnosis. We categorized reasons for screening underuse as a potential failure at each of the following steps required for HCC screening: receipt of regular outpatient care, recognition of liver disease, recognition of cirrhosis, screening orders in patients with cirrhosis, and adherence to screening ultrasound appointments. Among 1,014 patients with cirrhosis with HCC, only 377 (37.2%) had regular outpatient care in the year before HCC presentation. Consistent screening was observed in 93 (24.7%) patients under regular outpatient care, whereas 161 (42.7%) had inconsistent screening and 123 (32.6%) no screening. We found screening underuse related to failures at each step in the screening process, although nearly half (49.6%) were due to lack of screening orders in patients with known cirrhosis. Conclusion: The most common reasons for HCC screening underuse in patients with cirrhosis are lack of regular outpatient care and lack of screening orders in those with known cirrhosis, highlighting the need for interventions targeted at these steps to increase HCC screening use. (Hepatology Communications 2021;0:1-9).

Barriers to Surveillance for Hepatocellular Carcinoma in a Multicenter Cohort

“…Prior studies suggest that the former is the more common, with patients typically adhering with surveillance orders are present. 45 These limitations should be considered in light of the study’s notable strengths, including a large multicenter cohort from multiple practice settings around the US.…”

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.…”

Holistic management of hepatocellular carcinoma: The hepatologist's comprehensive playbook

“…20 Additional studies have also supported that referral to a hepatologist is associated not only with improved rates of surveillance but also with improved survival (Table 2). 21,[23][24][25][26][27] Studies evaluating primary care physician practices note that low rates of HCC surveillance may be due to lack of knowledge of current recommendations or the benefits of surveillance, presence of concerns about the cost of surveillance and inability to effectively communicate with patients about reasons for HCC surveillance, and lastly to the perception that there are more important issues to manage during clinic visits. 28 A particularly interesting challenge for primary care physicians may be the timing of referral for patients with NAFLD to a hepatologist given the ongoing rise in this condition and the susceptibility to HCC in this population.…”